Individual and interpersonal characteristics that influence male-dominated sexual decision-making and inconsistent condom use among married HIV serodiscordant couples in Gujarat, India: results from the positive Jeevan Saathi study

Sexual violence and self-reported sexually transmitted infections among women in sub-Saharan Africa

Sexual violence has proven to be associated with sexually transmitted infections (STIs) in sub-Saharan Africa (SSA). We examined the association between sexual violence and self-reported STIs (SR-STIs) among women in sexual unions in 15 sub-Saharan African countries. This was a cross-sectional study involving the analysis of data from the Demographic and Health Surveys (DHS) from 15 countries in SSA. A total sample of 65,392 women in sexual unions were included in the final analysis. A multilevel binary logistic regression analysis was carried out and the results were presented using adjusted odds ratios (aOR) at 95% Confidence Interval (CI). Women who experienced sexual violence in the last 12 months were more likely to self-report STIs compared to those who did not experience sexual violence [aOR = 1.76, 95% CI = 1.59-1.94]. Compared to women in Angola, those who were in Mali, Nigeria, Sierra Leone, Uganda, and Liberia were more likely to self-report STIs while those in Burundi, Cameroon, Chad, Ethiopia, Malawi, Rwanda, South Africa, Zambia, and Zimbabwe were less likely to self-report STIs. The study has revealed variations in the country level regarding the prevalence of sexual violence and SR-STI in the last 12 months among women in sexual unions in the selected countries. This study has demostrated that sexual violence in the last 12 months is associated with SR-STIs among women in sexual unions. Moreover, factors that predict SR-STIs were observed in this study. Policymakers and agencies that matter could consider the factors identified in this study when designing policies or strengthening existing ones to tackle STIs among women in SSA. To accelerate the progress towards the achievement of Sustainable Development Goal 3, its imperative efforts and interventions must be intensified in SSA to reduce sexual violence which will go a long way to reduce SR-STIs among women.

HIV-related challenges and women's self-response: A qualitative study with women living with HIV in Indonesia

HIV infection is a major public health concern, with a range of negative impacts on People Living with HIV (PLHIV). A qualitative study in Yogyakarta, Indonesia, using in-depth interviews with 26 Women Living with HIV (WLHIV) was conducted to understand HIV risk factors and impact and their access to HIV care services. This paper describes the self-response of WLHIV towards negative HIV-related experiences facing them and adds to the existing literature which tends to focus on HIV impact only, as opposed to strategies that many WLHIV have used to empower and educate themselves and their family/community. Participants were recruited using the snowball sampling technique. Data analysis was guided by a qualitative data analysis framework. Our study highlighted that WLHIV experienced psychological challenges, stigma and discrimination. However, they demonstrated remarkable self-response and capacity in pursuing effective strategies and support to protect themselves, and educating themselves and others around them to rebuild trust and regain respect and acceptance. Our findings indicate that the needs of WLHIV should be addressed through policy and practice to help them cope with HIV-related psychological and social challenges effectively. Family and community members seem to play an important role in those negative challenges against WLHIV, thus there is also a need for HIV education programs for family and community members to enhance their HIV-health literacy and acceptance of PLHIV.

HIV-serodifferent couples' perspectives and practices regarding HIV prevention strategies: A mixed methods study

A substantial proportion of heterosexually acquired HIV infections in the U.S. occur between partners in primary relationships characterized by mixed HIV status. The U.S. Centers for Disease Control and Prevention have issued guidelines prioritizing HIV-serodifferent couples for primary HIV prevention, including treatment-as-prevention and pre-exposure prophylaxis (PrEP). Yet, very little research has been conducted to understand the perspectives and practices of HIV-serodifferent couples regarding HIV prevention strategies in the U.S. To help fill this gap, we conducted a mixed methods study with 27 mostly Black/African American and Latinx HIV-serodifferent heterosexual couples residing in New York City to explore their knowledge, attitudes, practices, and perspectives regarding combination HIV prevention, including condoms, PrEP and viral control. All couples expressed the desire to maintain viral suppression in the HIV-positive partner, which was not always achieved. There was considerable heterogeneity in the use of HIV prevention methods by couples; and several patterns emerged that were largely driven by gender and relationship dynamics. Female partners, in particular, expressed high levels of anxiety around transmission of HIV and thus desired multiple methods of protection. Healthcare providers should consider couples' psychosocial well-being, relationship quality, and other motivational factors when helping to tailor HIV preventative care for mixed-status couples.

Psychological and Social Impact of HIV on Women Living with HIV and Their Families in Low- and Middle-Income Asian Countries: A Systematic Search and Critical Review

Human Immunodeficiency Virus (HIV) infection adds a significant burden to women in Low- and Middle-Income Countries (LMICs), often leading to severe detrimental impact, not only on themselves, but also on their families and communities. Given that more than half of all people living with HIV globally are females (53%), this review seeks to understand the psychological and social impact of HIV infection on Women Living with HIV (WLHIV) and their families in LMICs in Asia, and the interrelationships between one impact and another. A systematic review was conducted to find literature using the following databases: Medline, PsycINFO, CINAL, Emcare, Scopus and ProQuest. Research articles included in this review were selected based on the following inclusion criteria: conducted in LMICs in Asia, published in English language between 1 January 2004 and 31 December 2021, had full text available, involved WLHIV (married and unmarried) and explored the psychological and social impacts of HIV on these women and their families. Critical appraisal tools developed by Joanna Briggs Institute (JBI) were used to assess the methodological quality of the studies, and thematic narrative synthesis was used to analyse the findings. A total of 17 articles met the inclusion criteria. The review showed that HIV has a range of negative psychological consequences on WLHIV, such as stress, fear, worry, anxiety and depression, as well as social impacts on the women and their families, including stigma, discrimination and family separation. The findings indicate the need for targeted interventions-specific to WLHIV-that address the psychological challenges, stigma and discrimination these women and their families face. These interventions should also incorporate education and sustainable support structures for WLHIV and their families.

Cultural and religious determinants of HIV transmission: A qualitative study with people living with HIV in Belu and Yogyakarta, Indonesia

As a part of a larger qualitative study to understand HIV-risk factors and impacts on people living with HIV (PLHIV) (52 women and 40 men) in Belu and Yogyakarta, Indonesia, this paper reports the influences of cultural practices and religious beliefs on sexual relationships and behaviours of participants as contributors for HIV transmission. This study was conducted from June to December 2020. Data collection was conducted using one-one-one in-depth interviews. Participants were recruited using the snowball sampling technique. Data analysis was guided by a qualitative data analysis framework. The findings showed that cultural practices in Belu related to the use of bride wealth, managing spousal disputes, marriage, and condom use, influenced spousal relationships and sexual behaviours or practices which contributed to HIV transmission. Javanese cultural practices and expectation of an ‘ideal wife’, Islamic religious beliefs about expected husband-wife relationships, forbidden premarital sex, and the participants’ individual interpretation of their religious beliefs about condom use spousal sexual relations, also influenced spousal sexual relations and behaviours, which supported HIV transmission among the participants. The findings indicate the need for HIV education programs that address cultural practices and religious beliefs for community members and population groups to enhance their understanding about HIV, condom use, and how cultural practices and religious beliefs play a role in HIV transmission. The findings also indicate the need for involvement of religious leaders in HIV education programs to bring insights to people and help them interpret their religious beliefs in health promoting ways. Future studies that explore different aspects of culture and religion which may contribute to HIV transmission are recommended.

"I Just Decided to Stop:" Understanding PrEP Discontinuation Among Individuals Initiating PrEP in HIV Care Centers in Kenya

BACKGROUND

Preexposure prophylaxis (PrEP) discontinuation rates in clinical trials and demonstration projects have been well characterized; however, little is known about discontinuation in routine public health settings in sub-Saharan Africa. Understanding discontinuation in nonstudy settings is important for establishing expectations for PrEP continuation in national programs and for facilitating effective PrEP scale-up.

METHODS

We conducted in-depth interviews with 46 individuals who had initiated PrEP at 25 HIV comprehensive care clinics (CCCs) in central and western Kenya and whose clinic records indicated they had discontinued.

RESULTS

Many of our study participants discontinued PrEP when their perceived risk decreased (eg, hiatus or end of a sexual relationship or partner known to be living with HIV became virally suppressed). Others reported discontinuation due to side effects, daily pill burden, preference for condoms, or their partner's insistence. Participant narratives frequently described facility level factors such as stigma-related discomforts with accessing PrEP at CCCs, inconvenient clinic location or operating hours, long wait times, and short refill dates as discouraging factors, suggesting actionable areas for improving PrEP access and continuation.

CONCLUSION

Clients frequently make intentional decisions to discontinue PrEP as they weigh different prevention options within the context of complex lives. Many clients will decide to discontinue PrEP when perceiving themselves to be at reduced risk and PrEP counseling must include provisions for addressing seasons of risk. PrEP will not be the right prevention method for everyone, or forever. Expanding PrEP access points and increasing sex-positive messaging may facilitate PrEP being a better option for many.

Associations of intimate partner violence and reproductive coercion with contraceptive use in Uttar Pradesh, India: How associations differ across contraceptive methods

Intimate partner violence (IPV) and reproductive coercion (RC)-largely in the form of pressuring pregnancy-appear to contribute to low use of contraceptives in India; however, little is known about the extent to which these experiences differentially affect use of specific contraceptive methods. The current study assessed the association of IPV and RC with specific contraceptive methods (Intrauterine Devices [IUDs], pills, condoms) among a large population-based sample of currently married women (15-49 years, n = 1424) living in Uttar Pradesh. Outcomes variables included past year modern contraceptive use and type of contraceptive used. Primary independent variables included lifetime experience of RC by current husband or in-laws, and lifetime experiences of physical IPV and sexual IPV by current husband. Multivariate logistic regression models were developed to determine the effect of each form of abuse on women's contraceptive use. Approximately 1 in 7 women (15.1%) reported experiencing RC from their current husband or in-laws ever in their lifetime, 37.4% reported experience of physical IPV and 8.3% reported experience of sexual IPV by their current husband ever in their lifetime. Women experiencing RC were less likely to use any modern contraceptive (AOR: 0.18; 95% CI: 0.9-0.36). Such women also less likely to report pill and condom use but were more likely to report IUD use. Neither form of IPV were associated with either overall or method specific contraceptive use. Study findings highlight that RC may influence contraceptive use differently based on type of contraceptive, with less detectable, female-controlled contraceptives such as IUD preferred in the context of women facing RC. Unfortunately, IUD uptake remains low in India. Increased access and support for use, particularly for women contending with RC, may be important for improving women's control over contraceptive use and reducing unintended pregnancy.

Does having a mobile phone matter? Linking phone access among women to health in India: An exploratory analysis of the National Family Health Survey

BACKGROUND

The disruptive potential of mobile phones in catalyzing development is increasingly being recognized. However, numerous gaps remain in access to phones and their influence on health care utilization. In this cross-sectional study from India, we assess the gaps in women's access to phones, their influencing factors, and their influence on health care utilization.

METHODS

Data drawn from the 2015 National Family Health Survey (NFHS) in India included a national sample of 45,231 women with data on phone access. Survey design weighted estimates of household phone ownership and women's access among different population sub-groups are presented. Multilevel logistic models explored the association of phone access with a wide range of maternal and child health indicators. Blinder-Oaxaca (BO) decomposition is used to decompose the gaps between women with and without phone access in health care utilization into components explained by background characteristics influencing phone access (endowments) and unexplained components (coefficients), potentially attributable to phone access itself.

FINDINGS

Phone ownership at the household level was 92·8% (95% CI: 92·6-93·0%), with rural ownership at 91·1% (90·8-91·4%) and urban at 97.1% (96·7-97·3%). Women's access to phones was 47·8% (46·7-48·8%); 41·6% in rural areas (40·5-42·6%) and 62·7% (60·4-64·8%) in urban. Phone access in urban areas was positively associated with skilled birth attendance, postnatal care and use of modern contraceptives and negatively associated with early antenatal care. Phone access was not associated with improvements in utilization indicators in rural settings. Phone access (coefficient components) explained large gaps in the use of modern contraceptives, moderate gaps in postnatal care and early antenatal care, and smaller differences in the use of skilled birth attendance and immunization. For full antenatal car, phone access was associated with reducing gaps in utilization.

INTERPRETATION

Women of reproductive age have significantly lower phone access use than the households they belong to and marginalized women have the least phone access. Existing phone access for rural women did not improve their health care utilization but was associated with greater utilization for urban women. Without addressing these biases, digital health programs may be at risk of worsening existing health inequities.

A cross-sectional analysis of intimate partner violence and family planning use in rural India

BACKGROUND

Intimate partner violence (IPV) has been shown to be associated differentially with contraceptive use based on type, with IPV more likely among pill users and less likely among condom users. Recent increases in IUD uptake allow consideration of this type of contraceptive. We assessed the association between self-reported IPV and self-reported contraceptive use, by type, among non-pregnant married women in rural India in a region with higher than average IUD use.

METHODS

We assessed the association between past 12-month IPV (physical, sexual, or any) and past 3-month contraceptive use (condom, pill, IUD, or any modern method) using crude and adjusted multinomial logistic regression models.

FINDINGS

Among the 1001 women included, 109 (10·9%) reported experiencing physical IPV and 27 (2·7%) reported experiencing sexual IPV in the past 12 months. Women experiencing physical IPV were significantly less likely to use condoms (adjusted relative risk ratio [RRR]: 0·54, 95% confidence interval [CI]: 0·30-0·98, p = 0·042) than women not experiencing violence. There was a trend towards increased IUD use among women experiencing physical IPV (adjusted RRR: 1·78, 95% CI: 0·91-3·41, p = 0·091) compared to those not experiencing physical IPV, but this did not reach statistical significance.

INTERPRETATION

Our findings suggest that women who experience physical IPV in India are less likely to use condoms and may be more likely to use IUDs than women without exposure to IPV. This research expands on prior findings suggesting higher uptake of women-controlled contraceptives among women contending with IPV in India.

"Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?" the condom quandary among PrEP users and health care providers in Kenya

Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.

A cross-sectional evaluation of HIV testing practices among women in the rural Dominican Republic

Background

The Dominican Republic (DR) ranks among nations with the highest burden of HIV in the Caribbean. Cultural and gender roles in rural areas of the DR may place women at increased HIV risk. However, little is known about sexual health and HIV testing behaviors among women in the rural DR.

Methods

We conducted a needs assessment among a systematic sample of adult women in a rural DR community in 2016. Demographic and behavioral attributes related to HIV testing, sexual health, and healthcare utilization were evaluated. Poisson regression analysis was used to identify demographics and behaviors associated with having had a previous HIV test. Significance was defined as a p-value < 0.05.

Results

Among 105 women evaluated, 77% knew someone with HIV and 73% of women reported that they would be very or extremely likely to take an HIV test if offered. Only 68% reported a previous HIV test, including 47% who were tested over 2 years prior. Barriers to HIV testing included low risk perception (23%), distance or requisite travel (13%), and discomfort being tested (11%). Women who had never been tested for HIV were more likely than those who had been tested to be older (p = 0.03), to have a lower level of education (p = 0.04), and to have never been tested for other sexually transmitted infections (STI; p <  0.01). In the Poisson multiple regression model, the only significant predictor of having had an HIV test was having had an STI test (p = 0.03).

Conclusions

In the rural DR, numerous barriers contribute to low prevalence of HIV testing among women. Most women report willingness to have an HIV test and many engage in routine health care, indicating that this population may benefit from incorporating HIV testing and other sexual health promotion activities into routine medical care.

Associations between intimate partner violence and married women's condom and other contraceptive use in rural India

Background The existing literature on the intersection between women's reports of spousal intimate partner violence (IPV) and contraceptive use in South Asia is conflicted. Results vary based on method of contraception use and form of violence (physical or sexual), and few examine the relationship between IPV and various methods of modern spacing contraceptive (MSC) use. This study examines associations between IPV and MSC use among a sample of married, not-currently pregnant couples in rural Maharashtra, India (n=861).

METHODS

Multinomial logistic regression models assessed wives' physical and sexual IPV victimisation (for the past 6-months) in relation to the wives' past 3-month MSC use (categorised as condom use, other MSCs [oral pills, Intrauterine device (IUD)] and no MSCs).

RESULTS

In terms of violence, 9% (n=78) and 4% (n=34) of wives reported recent physical and sexual IPV victimisation, respectively. The majority (72%; n=621) did not use any MSC method in the past 3 months; 14% (n=119) reported recent condom use, and the same proportion reported other MSC use. Recent physical IPV was associated with increased likelihood of recent condom use (AOR: 2.46, 95% CI: 1.20, 5.04), and recent sexual IPV was associated with increased likelihood of recent use of other MSC (AOR: 3.27, 95% CI: 1.24, 8.56).

CONCLUSIONS

These findings reinforce the need for integration of counselling around IPV prevention and intervention programming into existing family planning services targeting married couples in rural Maharashtra, India.

A Qualitative Investigation of the Impact of a Livelihood Intervention on Gendered Power and Sexual Risk Behaviors Among HIV-Positive Adults in Rural Kenya

Despite the recognized links between food insecurity, poverty, and the risk of HIV/AIDS, few randomized trials have evaluated the impact of livelihood interventions on HIV risk behaviors. The current study draws upon data collected from a qualitative process evaluation that was embedded into a pilot randomized controlled trial that tested whether a multisectoral agricultural intervention (Shamba Maisha) affected the HIV-related health of HIV-positive adults in rural Kenya. In the current study, we drew upon longitudinal, in-depth interviews with 45 intervention participants and nine control participants (N = 54) in order to examine the impacts of the intervention on gendered power and sexual risk reduction among both women and men. Female and male participants in the intervention described positive changes in sexual practices and gendered power dynamics as a result of intervention participation. Changes included reduced sexual risk behaviors, improved gender-related power dynamics, and enhanced quality of intimate relationships. These findings illuminate how a multisectoral agricultural intervention may affect inequitable gender relations and secondary transmission risk. Further research is needed to explore how to best leverage agricultural interventions to address the important intersections between poverty and inequitable gender relations that shape HIV risks.

Sociocultural Influences on the Transmission of HIV From Husbands to Wives in Cambodia: The Male Point of View

The purpose of the study was to explore, within cultural and societal contexts, the factors of spousal HIV transmission as described by the experiences of HIV-positive Cambodian men. Using qualitative research methods, the researchers collected data from in-depth interviews with 15 HIV-positive Cambodian men of seroconcordant couples recruited from an HIV/AIDS clinic in Phnom Penh. Using a model of HIV transmission from husbands to wives, the questions were designed to elicit the men’s perspectives on the topics of promiscuity, masculinity, condom use in marriage, the image of the ideal Cambodian woman, and attitudes toward sex and marriage. Directed content analysis was used to analyze the interview data. The main results were as follows: (a) men involved with sex workers perceived this as a natural behavior and a necessary part of being an approved member in a male peer group, (b) married men never used condoms during sex with their wives prior to their HIV diagnosis, (c) men perceived a good wife as one who is diligent and loyal to her husband, and (4) men’s attitudes toward sex and marriage (e.g., sex perceived as a part of life pleasure) differed from those of their wives. Promoting honest spousal communication about sexuality, maintaining men’s marital fidelity, and increasing women’s comfort in the use of sexual techniques are suggested as strategies for reducing HIV transmission within marriage in Cambodia. Future interventions should focus on reshaping men’s behaviors and changing cultural norms to protect them and their spouses from HIV infection.

Pathways That Affect Wives' HIV Risk Among Serodiscordant Couples in India: Results From the Positive Jeevan Saathi Study

This study examined factors that mitigate or heighten HIV risk among HIV-negative wives in serodiscordant relationships in Gujarat, India. Grounded theory was used to analyze 46 interviews (23 couples) where husbands were HIV-positive and wives were HIV-negative. A conceptual framework emerged from analysis from which we identified five pathways and four key behaviors: (a) safer sex, (b) no sex, (c) coercive sex, and (d) unprotected sex. Most couples either practiced safe sex or abstained from sex. Factors such as wives' assertiveness, a wife's fear of acquiring HIV, mutual understanding, positive sex communication, and a husband's desire to protect wife influenced safe sex/sexual abstinence. Factors such as desire for children, a husband's alcohol use, and intimate partner violence influenced coercive and unprotected sex. Counseling topics on sex communication, verbal and non-verbal safer sex strategies, as well as addressing intimate partner violence and alcohol use may be important in preventing risk to HIV-negative wives.

Predictors of couple HIV counseling and testing among adult residents of Bukomero sub-county, Kiboga district, rural Uganda

Background

Studies have shown that couple HIV counseling and testing (CHCT) increased rates of sero-status disclosure and adoption of safer sexual behaviors with better linkage to treatment and care. However, current evidence suggests that new HIV infections are occurring among heterosexual couples in stable relationships where the majority of the individuals are not aware of their partner’s serostatus. This study examined the predictors of CHCT uptake among married or cohabiting couples of Bukomero sub-county Kiboga district in Uganda.

Methods

This cross-sectional correlational study was conducted among 323 individuals who were either married or cohabiting, aged 18–49 years. Participants were enrolled from randomly selected households in Bukomero sub-county. Data were collected using an interviewer-administered questionnaire on socio-demographics, self-rating on awareness of CHCT benefits, couple discussion about HIV testing and CHCT practices. Couples were compared between those who had reported to have tested as a couple and those who had not. Binary logistic regression was performed to determine the adjusted odds ratio [aOR] and 95 % confidence intervals [CI] for CHCT uptake and the other independent variables.

Results

Of the participants 288 (89.2 %) reported to have ever taken an HIV test only 99 (34.4 %) did so as a couple. The predictors of testing for HIV as a couple were discussing CHCT with the partner (adjusted odds ratio 4.95[aOR], 95 % confidence interval [CI]:1.99–12.98; p < 0.001), awareness of CHCT benefits (aOR 3.23; 95 % CI 1.78–5.87; p < 0.001) and having time to test as a couple (aOR 2.61; 95 % CI 1.22–5.61; p <0.05).

Conclusion

Uptake of HIV counseling and testing among couples was low. Discussing CHCT with partner, awareness of CHCT benefits, and availability of time to test as a couple were predictive of CHCT uptake. Thus CHCT campaigns should emphasize communication and discussion of HIV counseling and testing among partners.