Expanding the relationship context for couple-based HIV prevention: Elucidating women's perspectives on non-traditional sexual partnerships

Development and Empirical Test of the Research-Informed South African Relationship Functioning Assessment (SARFA)

Intimate partners play an important role in chronic diseases. Despite the chronic disease burden increase in sub-Saharan Africa, very few culturally-relevant quantitative measures of intimate relationship functioning are available. We conducted an empirical investigation evaluating the psychometric properties of the South African Relationship Functioning Assessment (SARFA) assessing healthy relationship functioning in N = 150 community members (50% women; M age = 27.2 years) living in the Vulindlela area of KwaZulu-Natal, South Africa. Item development was based on prior qualitative research from two South African communities. All assessments were conducted in isiZulu, participants' primary language. An exploratory factor analysis was conducted on the initial 39-item measure. The best-fitting model consisted of one factor with 22 items. The SARFA's internal consistency was α = .94. Convergent validity was observed via significant positive associations (all rs ≥ .38, p < .001) between the SARFA's total score and measures of trust, emotional intimacy, constructive communication, sexual satisfaction, and relationship control (women only). Divergent validity was observed for women only. Encouraging initial psychometric properties of a culturally-relevant measure of relationship functioning in KwaZulu-Natal may have relevance to other communities and potential to be used in research involving couples and health in chronic disease-burdened communities.

Exploring ecosocial contexts of alcohol use and misuse during the COVID-19 pandemic among urban refugee youth in Kampala, Uganda: Multi-method findings

Urban refugees may be disproportionately affected by socio-environmental stressors that shape alcohol use, and this may have been exacerbated by additional stressors in the COVID-19 pandemic. This multi-method study aimed to understand experiences of, and contextual factors associated with, alcohol use during the pandemic among urban refugee youth in Kampala, Uganda. We conducted a cross-sectional survey (n = 335), in-depth individual interviews (IDI) (n = 24), and focus groups (n = 4) with urban refugee youth in Kampala. We also conducted key informant interviews (n = 15) with a range of stakeholders in Kampala. We conducted multivariable logistic regression analyses with survey data to examine socio-demographic and ecosocial (structural, community, interpersonal) factors associated with ever using alcohol and alcohol misuse. We applied thematic analyses across qualitative data to explore lived experiences, and perceived impacts, of alcohol use. Among survey participants (n = 335, mean age= 20.8, standard deviation: 3.01), half of men and one-fifth of women reported ever using alcohol. Among those reporting any alcohol use, half (n = 66, 51.2 %) can be classified as alcohol misuse. In multivariable analyses, older age, gender (men vs. women), higher education, and perceived increased pandemic community violence against women and children were associated with significantly higher likelihood of ever using alcohol. In multivariable analyses, very low food security, relationship status, transactional sex, and lower social support were associated with increased likelihood of alcohol misuse. Qualitative findings revealed: (1) alcohol use as a coping mechanism for stressors (e.g., financial insecurity, refugee-related stigma); and (2) perceived impacts of alcohol use on refugee youth health (e.g., physical, mental). Together findings provide insight into multi-level contexts that shape vulnerability to alcohol mis/use among urban refugee youth in Kampala and signal the need for gender-tailored strategies to reduce socio-environmental stressors.

Translation of HIV/AIDS knowledge into behavior change among secondary school adolescents in Uganda: A review

The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pandemic is primarily affecting young people worldwide, with those between the ages of 15 and 24 accounting for nearly half of all new infections. This paper was written to effectively translate HIV/AIDS knowledge into actionable behavioral changes among secondary school students in Uganda by empowering them with comprehensive information, fostering a deeper understanding of preventive measures, and facilitating the development of responsible and informed decision-making skills, thereby reducing the incidence of HIV/AIDS transmission within this demographic. There is a relationship between risk perception and behavior change in HIV/AIDS prevention among high school students. This can be explained by the high proportion of secondary school students who think they are at risk of HIV infection; this perception may be related to having had early sex, being sexually active, and knowing someone has died of HIV. High school students regularly engage in risky sexual behaviors, such as not using condoms and having multiple lifelong partners. Student behavior is significantly influenced by HIV and AIDS prevention initiatives such as youth-friendly services, peer education, and condom use.

Psychological and physical intimate partner violence and sexual risk behavior among South African couples: a dyadic analysis

This study aimed to examine intimate partner violence (IPV) as it relates to both partners' perceptions of IPV and sexual behaviors, considering how their IPV might be interdependent within the relationship dynamics. The sample consisted of 713 female-male dyads in which women were pregnant and living with HIV in rural South Africa. Using an actor-partner interdependence model (APIM), we examined the interdependent influence of psychological and physical IPV on men by their female partners and psychological and physical IPV on women by their male partners on sexual risk behavior. The APIM model found there were no actor (b = -0.06, SE = 0.05, p = .221) or partner (b = -1.2, SE = 0.06, p = .056) effects contributing to protected sex by female IPV victimization. In contrast, significant actor (b = -0.28, SE = 0.06, p < .001) and partner (b = -0.29, SE = 0.06, p < .001) effects for protection were related to male IPV victimization. The model also found that the covariate of female HIV disclosure was associated with both male (b = 0.5, SE = 0.12, p < .001) and female protected sexual intercourse (b = 0.58, SE = 0.1, p < .001). Female HIV disclosure was related to an increased likelihood of protected sex by both male and female partners. As male partners reported more IPV victimization, the likelihood of protected sex between male and female partners decreased.Trial registration: ClinicalTrials.gov identifier: NCT02085356.

Making the Case for Joint Decision-Making in Future Multipurpose Prevention Technology (MPT) Choice: Qualitative Findings on MPT Attribute Preferences from the CUPID Study (MTN-045)

Introduction

Young women in sub‐Saharan Africa account for two‐thirds of all new HIV infections and face high rates of unintended pregnancy. Multipurpose prevention technologies (MPTs) are promising products under development that are designed to simultaneously prevent HIV and unintended pregnancy. Since MPTs will be used in the context of sexual relationships, ensuring acceptability and use requires understanding the role of male partners in MPT use decision‐making.

Methods

This paper draws on qualitative data from 39 couples enrolled in the Microbicide Trials Network (MTN) 045 study, conducted in 2019–2020. Partners completed a discrete choice experiment (DCE), first separately and then jointly, to measure preferences for future MPT attributes and then completed a qualitative interview. We also draw on quantitative data from interviewer observation about who dominated the decision‐making process during the joint DCE. Content analysis was used to examine (1) how couples made decisions on existing non‐MPT HIV and pregnancy prevention products; (2) how couples made decisions on future ideal‐MPT product during the DCE; and (3) how these decision‐making processes varied by decision‐making dominance (10 male, 10 female and 19 equal) and interview type (19 joint and 20 separate).

Results

Existing non‐MPT product decisions focused on trust between partners and product attributes, while future ideal‐MPT product decisions exclusively focused on product attributes. Across existing and future products, preferences for product attributes varied by gender. Male partners were most concerned with limiting side effects impacting sexual pleasure, female partners were most concerned with limiting side effects causing physical symptoms and both were concerned with the return to fertility. Across all dominance and interview types, couples reported making decisions together and female partners were often able to negotiate with male partners for their preferred product or set of product attributes.

Conclusions

Research activities in this study provided an opportunity for couples to openly present their product attribute preferences to their partner, learn about their partner's attribute preferences, negotiate for their ideal set of attributes and ultimately choose attributes that benefited the couple without disempowering the female partner. Future research should focus on the utility of couple‐based decision‐making aids or similar tools for facilitating joint MPT decision‐making.

Relational Factors and HIV Testing Practices: Qualitative Insights from Urban Refugee Youth in Kampala, Uganda

Despite the global phenomenon of refugee urbanization, little is known of relational contexts that shape HIV testing among urban refugee youth. We explored perspectives, experiences, and preferences for social support in HIV testing among refugee youth aged 16-24 in Kampala, Uganda. We conducted five focus groups with refugee youth (n = 44) and five in-depth key informant interviews. Participant narratives signaled relational contexts shaping HIV testing included informal sources (intimate partners and family members) and formal sources (peer educators and professionals). There was heterogeneity in perspectives based on relationship dynamics. While some felt empowered to test with partners, others feared negative relationship consequences. Participant narratives reflected kinship ties that could facilitate testing with family, while others feared coercion and judgment. Peer support was widely accepted. Professional support was key for HIV testing as well as conflict-related trauma. Findings emphasize bonding and bridging social capital as salient components of enabling HIV testing environments.

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

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

Predictors of HIV Status Disclosure to Sexual Partners Among People Living with HIV in Brazil

The objective of this study was to identify the factors associated with the non-disclosure of HIV seropositivity among people living with HIV/AIDS undergoing antiretroviral treatment. A cross-sectional study was carried out in five HIV clinics in the interior of the state of São Paulo, Brazil. Logistic regression analysis was used to determine independent predictors of HIV status disclosure. It was found that 68.5% revealed their HIV seropositivity to their most recent sexual partner. The variables "casual partner" [OR 19.08, 95% CI (4.08, 20.23), p = 0.001], "sexual partners with negative HIV or unknown HIV" [OR 4.54, 95% CI (1.58, 1.01), p = 0.005], "multiple sexual partners" [OR = 3.17, 95% CI (1.34, 7.35), p = 0.009], and "lack of communication with the partner on HIV prevention"[OR = 8.3, 95% CI (3.88, 16.61), p = 0.001] were independently associated with non-disclosure of the diagnosis. Future HIV prevention interventions should encourage open communication between sexual partners.

Development and Validation of the Couple Sexual Satisfaction Scale for HIV and Sexual Health Research

Sexual satisfaction is an important dimension of relationship quality with implications for sexual and reproductive health (SRH), and HIV prevention, care, and treatment. We developed and validated the Couple Sexual Satisfaction Scale (CSSS) with heterosexual couples in sub-Saharan Africa. Using data from qualitative interviews with 94 partnered women and men in Swaziland and Malawi, we generated a 22-item scale and administered it to 211 couples with at least one partner living with HIV in Malawi. We performed an exploratory factor analysis (EFA) to identify and confirmatory factor analysis (CFA) to test the factor structure. To assess validity, we tested for associations between the CSSS and relationship quality, consistent condom use, and intimate partner violence (IPV) using generalized estimating equations. The EFA yielded two factors, general sexual satisfaction (13-item CSSS-Gen subscale, e.g., "I am satisfied with the sweetness of sex in our relationship") and HIV-specific sexual satisfaction (4-item CSSS-HIV subscale, e.g., "My appetite for sex has gone down due to HIV"), accounting for 78% of the shared variance. The CFA supported the two-factor solution: χ²(118) = 203.60; CFI = 0.909; SRMR = 0.057; RMSEA = 0.058. Participants with higher CSSS-Gen scores reported higher coital frequency and relationship quality (intimacy, trust, unity, equality, relationship satisfaction, commitment, partner social support), and less consistent condom use, physical IPV, and emotional IPV. Participants with higher CSSS-HIV scores reported higher coital frequency and relationship quality (trust, partner support), and less consistent condom use, and sexual IPV. The CSSS demonstrated good psychometric properties and provides new opportunities to study sexual reproductive health and HIV-related health behaviors among couples in sub-Saharan Africa.

"It really proves to us that we are still valuable": Qualitative research to inform a safer conception intervention for men living with HIV in South Africa

Objective

Many men living with HIV want to have children. Opportunities to reduce periconception HIV transmission include antiretroviral therapy as prevention, pre-exposure prophylaxis, limiting condomless sex to peak fertility, and sperm processing. Whether men have knowledge of or want to adopt these strategies remains unknown.

Methods

We conducted focus group discussions (FGDs) with men accessing HIV care in South Africa in 2014 to inform a safer conception intervention for men. Eligible men were 25–45 years old, living with HIV, not yet accessing treatment, and wanting to have a child with an HIV-negative or unknown serostatus female partner (referred to as the “desired pregnancy partner”). FGDs explored motivations for having a healthy baby, feasibility of a clinic-based safer conception intervention, and acceptability of safer conception strategies. Data were analyzed using thematic analysis.

Results

Twelve participants from three FGDs had a median age of 37 (range 23–45) years, reported a median of 2 (range 1–4) sexual partners, and 1 (range 1–3) desired pregnancy partner(s). A third (N = 4) had disclosed HIV-serostatus to the pregnancy partner. Emergent themes included opportunities for and challenges to engaging men in safer conception services. Opportunities included enthusiasm for a clinic-based safer conception intervention and acceptance of some safer conception strategies. Challenges included poor understanding of safer conception strategies, unfamiliarity with risk reduction [versus “safe” (condoms) and “unsafe” (condomless) sex], mixed acceptability of safer conception strategies, and concerns about disclosing HIV-serostatus to a partner.

Conclusions

Men living with HIV expressed interest in safer conception and willingness to attend clinic programs. Imprecise prevention counseling messages make it difficult for men to conceptualize risk reduction. Effective safer conception programs should embrace clear language, e.g. undetectable = untransmittable (U = U), and support multiple approaches to serostatus disclosure to pregnancy partners.

The Influence of Shared or Separate Partner Residence on HIV Testing Among Latino Immigrants in the United States

BACKGROUND

The relationship context is influential in shaping HIV risk and preventive behaviors. Yet, there is little understanding about how shared or separate residence of partners shapes perceptions that affect HIV prevention.

METHODS

We explored how shared or separate residence from one's partner impacts HIV testing intentions among Latino immigrants in the USA. We analyzed data from 206 Latino immigrants residing in New York City, and examined three potential models to assess the relationships between partner residence, partner approval of HIV testing, and HIV testing behaviors.

RESULTS

Results indicated that shared residence was associated with greater partner approval to test for HIV (B = 0.48, 95% CI 0.01, 0.96, p = .04), and in turn, higher partner approval was associated with greater intention to test for HIV in the next 12 months (B = 0.38, 95% CI 0.15, 0.62., p < .01).

CONCLUSIONS

Results suggest the need to consider partner residency as an important factor in shaping determinants of HIV testing behaviors. Conceptualization of couples as living separately, across national borders, is warranted for couple-based health interventions given the current socio-political climate in the USA. Future research focused on couple-based HIV prevention should examine strategies and policies to preserve or strengthen partner dynamics among couples living apart.

Social representations of HIV/AIDS by older people and the interface with prevention

OBJECTIVE

To apprehend the social representations elaborated by older people about HIV/AIDS and to understand how they relate to the prevention of HIV infection.

METHOD

Descriptive and qualitative research based on the Theory of Social Representations with 42 older people assisted at primary care. Data were produced through in-depth interviews with a semi-structured instrument, processed in the IRaMuTeQ software, and analyzed by means of the descending hierarchical classification.

RESULTS

Five classes emerged: "HIV/AIDS: a problem of young people"; "Quality of life improvement for people living with HIV/AIDS"; "Vulnerability to HIV/AIDS among heterosexual women in a stable union"; "HIV/AIDS Information Network: process of creation and transformation of social representations" and "Prevention versus stigma".

FINAL CONSIDERATIONS

The social representations that older people have about HIV/AIDS influence the adoption of preventive measures negatively because stigma is present and HIV/AIDS is attributed to young men, and to men who have sex with other men.

Trust, Sexual Trust, and Sexual Health: An Interrogative Review

Trust is experienced almost constantly in all forms of social and interpersonal relationships, including sexual relationships, and may contribute both directly and indirectly to sexual health. The purpose of this review is to link three aspects of trust to sexual health: (1) the role of trust in sexual relationships; (2) the role of trust in sexually transmitted infection (STI) prevention, particularly condom use; and (3) the relevance of trust in sexual relationships outside of the traditional model of monogamy. The review ends with consideration of perspectives that could guide new research toward understanding the enigmas of trust in partnered sexual relations in the context of sexual and public health.

FACTORS ASSOCIATED WITH THE CONSISTENT USE OF THE MALE CONDOM AMONG WOMEN LIVING WITH HIV/AIDS

ABSTRACT Objective: to analyze the factors associated with the consistent use of the male condom among women living with HIV/aids. Method: an analytical study with a quantitative approach involving 140 women living with HIV/aids who at the time of the study had an active sexual life and receiving follow-up care at the Specialized Care Services. The data were collected by means of a questionnaire via individual interview and were later analyzed using the version 17.0 of the Statistical Package for Social Sciences software. Results: it was identified that the longer diagnostic time (p=0.029); (p=0.030), non-use of alcohol (p=0.022), and other drugs (p<0.001) prior to intercourse were factors associated with consistent condom use. Conclusion: strategies are needed to encourage women and their partners to use condoms in sex, as it is a proven method for the preventon of HIV transmission and acts as a barrier against other sexually transmitted infections.

Changing sex risk behaviors, gender norms, and relationship dynamics among couples in Cape Town, South Africa: Efficacy of an intervention on the dyad

RATIONALE

South Africa continues to experience new HIV infections, with the highest risk among Black Africans living in poor communities. Most HIV prevention interventions target women or men separately and only a small number target couples jointly.

OBJECTIVE

This study examines varying strategies to engage women and men around HIV prevention and improved couple interactions.

METHODS

The study comprises three arms: (1) a couple-based intervention delivered to women and men jointly; (2) women and men both offered a gender-focused intervention that is delivered to them separately; and (3) an intervention offered to women only and their male partners receive standard HIV testing and counseling (comparison arm). Between June 2010 and April 2012, men were identified in and around drinking establishments in a large disadvantaged community in Cape Town and asked to participate in the study if they drink regularly, had recent unprotected sex with their partner, and have a female partner who was willing to participate in the study.

RESULTS

A total of 299 couples completed the baseline assessment and 276 were included in the analysis of sexual risk, partner communication, conflict resolution, and gender norm outcomes at baseline and six-month follow-up. Couples that participated in the couple-level intervention and couples where both partners received the intervention separately had better couple-level gender norms than couples in the comparison arm (women only receive intervention). Further, couples in the couple-level intervention and the both partners exposed separately arms were more likely to have the man only report consistent condom use than neither partner report consistent condom use than couples in the comparison arm.

CONCLUSION

Community-based HIV prevention intervention programs need to consider strategies to engage women and men and, if feasible, reach both partners jointly. Couple-level interventions are promising to improve gender norms and subsequently improve health outcomes, including reduced HIV risk among women, men, and couples.

Beyond HIV-serodiscordance: Partnership communication dynamics that affect engagement in safer conception care

INTRODUCTION

We explored acceptability and feasibility of safer conception methods among HIV-affected couples in Uganda.

METHODS

We recruited HIV-positive men and women on antiretroviral therapy (ART) ('index') from the Uganda Antiretroviral Rural Treatment Outcomes cohort who reported an HIV-negative or unknown-serostatus partner ('partner'), HIV-serostatus disclosure to partner, and personal or partner desire for a child within two years. We conducted in-depth interviews with 40 individuals from 20 couples, using a narrative approach with tailored images to assess acceptability of five safer conception strategies: ART for the infected partner, pre-exposure prophylaxis (PrEP) for the uninfected partner, condomless sex timed to peak fertility, manual insemination, and male circumcision. Translated and transcribed data were analyzed using thematic analysis.

RESULTS

11/20 index participants were women, median age of 32.5 years, median of 2 living children, and 80% had HIV-RNA <400 copies/mL. Awareness of HIV prevention strategies beyond condoms and abstinence was limited and precluded opportunity to explore or validly assess acceptability or feasibility of safer conception methods. Four key partnership communication challenges emerged as primary barriers to engagement in safer conception care, including: (1) HIV-serostatus disclosure: Although disclosure was an inclusion criterion, partners commonly reported not knowing the index partner's HIV status. Similarly, the partner's HIV-serostatus, as reported by the index, was frequently inaccurate. (2) Childbearing intention: Many couples had divergent childbearing intentions and made incorrect assumptions about their partner's desires. (3) HIV risk perception: Participants had disparate understandings of HIV transmission and disagreed on the acceptable level of HIV risk to meet reproductive goals. (4) Partnership commitment: Participants revealed significant discord in perceptions of partnership commitment. All four types of partnership miscommunication introduced constraints to autonomous reproductive decision-making, particularly for women. Such miscommunication was common, as only 2 of 20 partnerships in our sample were mutually-disclosed with agreement across all four communication themes.

CONCLUSIONS

Enthusiasm for safer conception programming is growing. Our findings highlight the importance of addressing gendered partnership communication regarding HIV disclosure, reproductive goals, acceptable HIV risk, and commitment, alongside technical safer conception advice. Failing to consider partnership dynamics across these domains risks limiting reach, uptake, adherence to, and retention in safer conception programming.