Factors associated with consistent condom use among rural young women in South Africa

Uptake of multi-level HIV interventions and HIV-related behaviours among young people in rural South Africa

Combination HIV prevention packages have reduced HIV incidence and improved HIV-related outcomes among young people. However, there is limited data on how package components interact to promote HIV-related prevention behaviours. We described the uptake of HIV prevention interventions supported by Determined, Resilient, Empowered, AIDS-free, Motivated and Safe (DREAMS) Partnership and assessed the association between uptake and HIV-related behaviours among young people in rural KwaZulu-Natal, South Africa. We analysed two cohorts followed from May 2017 to December 2019 to evaluate the impact of DREAMS, covering 13-29 year-old females, and 13-35 year-old males. DREAMS interventions were categorised as healthcare-based or social. We described the uptake of interventions and ran logistic regression models to investigate the association between intervention uptake and subsequent protective HIV-related outcomes including no condomless sex and voluntary medical male circumcision (VMMC). For each outcome, we adjusted for socio-demographics and sexual/pregnancy history and reported adjusted odds ratios (aOR) and 95% confidence intervals (CI). Among 5248 participants, uptake of healthcare interventions increased from 2018 to 2019 by 8.1% and 3.7% for males and females respectively; about half of participants reported receiving both healthcare and social interventions each year. The most utilised combinations of interventions included HIV testing and counselling, school-based HIV education and cash transfers. Participation in social interventions only compared to no intervention was associated with reduced condomless sex (aOR = 1.60, 95%CI: 1.03-2.47), while participation in healthcare interventions only was associated with increased condomless sex. The uptake of interventions did not significantly affect subsequent VMMC overall. Among adolescent boys, exposure to school-based HIV education, cash transfers and HIV testing and counselling was associated with increase in VMMC (aOR = 1.79, 95%CI: 1.04-3.07). Multi-level HIV prevention interventions were associated with an increase in protective HIV-related behaviours emphasizing the importance of accessible programs within both school and community settings for young people.

Consistent condom use among Botswana's female population and associated factors

BACKGROUND

Botswana is one of the countries severely impacted by the HIV/AIDS pandemic. Despite an extensive HIV prevention campaign, the incidence of HIV, particularly among women, remains high. Condoms play a significant role in preventing new HIV infections, although men and women do not consistently use them.

OBJECTIVE

The study assessed the individual, relationship and community factors associated with consistent condom use among women in Botswana.

DESIGN

A cross-sectional study using secondary data drawn from a national survey on Gender-Based Violence Indicators in 2012.

METHODS

The primary survey sampled 639 women, aged 18 years and older, using a multistage procedure. The final sample size for the secondary analysis included a total of 480 women who were sexually experienced and had reported using condoms with their male partners. Multivariate logistic regression analysis was employed to assess the association between consistent condom use and the explanatory variables. The multivariate logistic regression adjusted for cluster/community random effects.

RESULTS

About 43% of the women used condoms consistently in the past year. Consistent condom use was more likely among women who were employed in the past year (adjusted odds ratio = 1.77; 95% confidence interval = 1.25-2.50). While, women who lived with their partners (adjusted odds ratio = 0.46; 95% confidence interval = 0.28-0.74), had non-Christian beliefs (adjusted odds ratio = 0.52; 95% confidence interval = 0.29-0.92), perceived that their partners would be angry if they ask to use a condom (adjusted odds ratio = 0.19; 95% confidence interval = 0.06-0.58) and perceived that their community says women need their husband's permission to do paid work (adjusted odds ratio = 0.56; 95% confidence interval = 0.38-0.83) were less likely to use condoms consistently.

CONCLUSION

Consistent condom use among Botswana's female population is suboptimal. Consistent condom use was higher among women with employment, and lower among women who lived with their partners, had non-Christian beliefs, feared their partners' reaction upon asking for condom use and held inequitable community gender beliefs. To enhance women's consistent use of condoms, friendly condom use information, female economic empowerment strategies and programmes that involve religious leaders and promote progressive and healthy masculine practices in Sexual Reproductive Health/HIV interventions should be considered.

Which Intervention Synergies Maximize AGYW's HIV Outcomes? A Classification and Regression Tree Analysis of Layered HIV Prevention Programming

INTRODUCTION

Intersecting behavioral, social, and structural factors increase adolescent girls' (AG) and young women's (YW) HIV vulnerability. Yet, understanding of optimal intervention synergies remains limited. We identified intervention combinations that statistically maximized reductions in AGYW's HIV-related risk.

METHODS

Using data collected in 2018 with Zambian AG (n = 487, aged 15-19 years) and YW (n = 505, aged 20-25 years) after 12-14 months exposure to Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (multisectoral HIV program), we used classification and regression trees to explore relationships between interventions (safe space/social asset building [SAB] and provision of/linkage to youth-friendly health services [YFHS], education social protection [Educ], economic social protection [Econ]) and HIV-related outcomes (HIV testing, consistent condom use, transactional sex, and sexual violence experience from partners and nonpartners).

RESULTS

Overall, 59.9% completed SAB and 81.5%, 35.4%, and 29.6% received YHFS, Educ, and Econ, respectively. For AG, HIV testing improved (from 73% to 83%) with exposure to all interventions, condom use improved with Econ (from 33% to 46%), transactional sex reduced with SAB + Educ, and sexual violence from partners and nonpartners reduced with Educ and SAB, respectively. For YW, HIV testing increased with Educ (from 77% to 91%), condom use increased with SAB + YFHS (from 36% to 52%), transactional sex reduced with combinations of all interventions, and sexual violence from partners reduced with YFHS and from nonpartners with SAB + Econ.

CONCLUSIONS

Tailored interventions might be more effective than uniform combination intervention packages in reducing AGYW's HIV risk. AG benefitted most from SAB and/or Educ while YFHS, Educ, and/or SAB reduced YW's HIV-related risk. Educational and asset-building interventions could have the greatest impact on AGYW's HIV risk.

"It doesn't exist, only other people have it, or it's bad luck": perceptions of HIV as barriers to its prevention in Bata

BACKGROUND

Currently, Africa is the region of the world where the highest number of new cases of HIV infection are registered. In 2022, Equatorial Guinea was the Central African country with the highest HIV prevalence (6.9%) and incidence (3.80 per 1,000 amongst the population of all ages). The main objective of this study was to determine the perceptions of HIV and the meanings given to it among the population of Equatorial Guinea in order to assess to what extent they represent a barrier to the prevention strategies implemented hitherto.

METHODS

A total of 30 semi-structured interviews and nine focal groups were carried out.

FINDINGS

The interviewees' testimonies revealed a combination of differing perceptions and meanings around HIV. In some cases, HIV was perceived as "a non-existent illness", and in others as "a disease of others", or as "a disease of bad luck". Other majority perceptions of HIV classed it as "a deadly disease" or "a sexual illness".

CONCLUSIONS

All these perceptions of HIV and the social representations constructed around it can represent a barrier to adopting preventive practices. Hence, in order to improve efficacy, efficiency, and effectiveness, it is recommended that HIV prevention policies take into account the heterogeneity of meanings linked to the different social groups that have contracted the virus.

The influence of type of sexual partnership on male condom use: empirical evidence from the South African construction industry

There are indications that gender has an effect on individual risk factors and pathways to HIV diagnoses and treatment. Furthermore, there is growing recognition that to improve HIV-related health outcomes for men, it is important to understand their experiences and perspectives. Perhaps because of the physical nature of construction work, the South African construction industry is dominated by men. Given that employed men are a hard-to-reach community population group, the construction workplace offers an ideal environment for data collection and delivery of non-health-facility-based HIV prevention and treatment interventions. Furthermore, workers in the construction industry have been identified as being at a heightened risk of acquiring HIV and AIDS because of work-related travel, the ubiquity of transactional sex around worker hostels and having an increased likelihood of multiple and concurrent sex partnerships. As a consequence, this study examines the association between condom use and sexual partnerships among men working in the construction industry. A purposive cross-sectional survey was used to collect data from 450 workers across 18 construction sites in the Western Cape province of South Africa. The types of sexual partnership had three categories: regular sex partnerships, casual sex partnerships and sex worker partnerships. Frequency of condom use was determined to be highest with casual sex partners (51.2%), followed by sex workers (40.6%) and regular sex partners (25.6%). Hierarchical multiple linear regression analysis was used to examine the demographic, experiential, behavioural and cognitive predictors of condom use across the three categories of sexual partnership. The results indicate that an individual's perception of control over condom use, and the perceived threat posed by HIV and AIDS are significantly associated with consistent condom use, even after accounting for differences in partner type. Implications of the findings are discussed, and directions for future research on the association between sexual partnerships and condom use are offered.

Assessing spatial patterns of HIV prevalence and interventions in semi-urban settings in South Africa. Implications for spatially targeted interventions

Equitable allocation of resources targeting the human immunodeficiency virus (HIV) at the local level requires focusing interventions in areas of the greatest need. Understanding the geographical variation in the HIV epidemic and uptake of selected HIV prevention and treatment programmes are necessary to identify such areas. Individual-level HIV data were obtained from a 2012 national HIV survey in South Africa. Spatial regression models on each outcome measure (HIV infection, sub-optimal condom use or non-anti-retroviral treatment (ART) adjusted for spatial random effects at the ward level were fitted using WINBUGS software. In addition, ward-level data was utilized to estimate condom use coverage and ART initiation rates which were obtained from routinely collected data in 2012. Ordinary Kriging was used to produce smoothed maps of HIV infection, condom use coverage and ART initiation rates. HIV infection was associated with individuals undertaking tertiary education [posterior odds ratio (POR): 19.53; 95% credible intervals (CrI): 3.22- 84.93]. Sub-optimal condom use increased with age (POR: 1.09; 95%CrI: 1.06-1.11) and was associated with being married (POR: 4.14; 95%CrI: 1.23-4.28). Non-ART use was associated with being married (POR: 6.79; 95%CrI: 1.43-22.43). There were clusters with high HIV infection, sub-optimal condom use, and non- ART use in Ekurhuleni, an urban and semi-urban district in Gauteng province, South Africa. Findings show the need for expanding condom programmes and/or strengthening other HIV prevention programmes such as pre-exposure prophylaxis and encouraging sustained engagement in HIV care and treatment in the identified areas with the greatest need in Ekurhuleni Metropolitan Municipality.

"I feel like it is asking if he is a stalker … but I also feel like it is asking if he cares": exploring young South African women and men's perceptions of the Sexual Relationship Power Scale

Background

Gender inequity and the subsequent health impacts disproportionately affect communities in the Global South. However, most gender equity measures, such as Pulerwitz’ (2000) Sexual Relationship Power Scale (SRPS), are developed and validated in the Global North and then applied in Global South settings without investigation of context applicability or validity. This study examines the SRPS’ validity evidence, comprehensiveness, and contemporary relevance for young South African women and men.

Methods

Between 2019 and 2021, 38 cognitive interviews (CIs) were conducted among previous participants of a South African youth cohort study ‘AYAZAZI’ (2015–2017) to explore youth’s perceptions of the SRPS. The SRPS measures women’s perceptions of their partner’s controlling behaviours, and men’s perceptions of their own controlling behaviours. Using CIs, participants responded to a 13-item adaptation of the SRPS for use among South African youth (strongly agree-strongly disagree), and then were asked to think-aloud their reasoning for responses, their understanding and perceived relevance of each item, and made overall suggestions for scale adaptations. An item appraisal coding process was applied, whereby Cognitive Coding assessed the types of cognitive problems youth had with understanding the items, and Question Feature Coding assessed which item features caused problems for participant understandings. Finally, youth recommendations for scale adaptations were summarized.

Results

Overall, 21 women and 17 men aged 21–30 participated in CIs in Durban and Soweto, South Africa. Cognitive Coding revealed 1. Comprehension issues, and 2. Judgements related to items’ applicability to lived experiences and identities (e.g., being unmarried). Question Feature Coding revealed items’ 1. Lack of clarity or vagueness in wording and 2. Logical problems in assumptions leading to multiple interpretations (e.g., item ‘my partner always need to know where I am’ interpreted as both controlling and caring behaviour). Multiple, overlapping issues revealed how many items failed to “fit” within the present-day living realities of South African youth. Youth recommended several item adaptations and additions, including strength-based items, to existing measures of gender equity and relationship power.

Conclusion

Given identified issues, several adaptations including revising items to be more inclusive, contemporary, context specific, relational, and strength-based are needed to validly measure gender equity and power dynamics within the relationships of South African youth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13686-9.

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.

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.

Sexual relationship power equity is associated with consistent condom use and fewer experiences of recent violence among women living with HIV in Canada

BACKGROUND

Sexual relationship power (SRP) inequities, including having a controlling partner, have not been widely examined among women living with HIV (WLWH). We measured prevalence, and key outcomes of relationship control among WLWH in Canada.

METHODS

Baseline data from WLWH (≥16 years), reporting consensual sex in the last month enrolled in a Canadian community-collaborative cohort study in British Columbia, Ontario, and Quebec, included Pulerwitz's (2000) SRP relationship control sub-scale. Scale scores were dichotomized into medium/low [score=1-2.82] vs. high relationship control [score=2.82-4], high scores=greater SRP equity. Cronbach's alpha assessed scale reliability. Bivariate analyses compared women with high vs. medium/low relationship control. Crude and adjusted multinomial regression examined associations between relationship control and condom use (consistent [ref], inconsistent, never), any sexual, physical and/or emotional violence, and physical and/or sexual violence (never [ref], recent [≤3 months ago], and previous [>3 months ago]).

RESULTS

Overall, 473 sexually active WLWH (33% of cohort), median age=39 (IQR=33-46), 81% on antiretroviral therapy and 78% with viral loads <50copies/mL were included. The sub-scale demonstrated good reliability (Cronbach's alpha=0.92). WLWH with high relationship control (80%) were more likely (p<0.05) to: be in a relationship; have no children; have greater resilience; and report less socio-structural inequities. In adjusted models, high relationship control was associated with lower odds of: inconsistent vs. consistent condom use (aOR:0.39[95%CI:0.18-0.85]); any recent (aOR:0.14[0.04-0.47]); as well as recent physical and/or sexual (aOR=0.05[0.02,0.17]) but not previous violence (vs. never).

DISCUSSION

Prioritizing relationship equity and support for WLWH is critical for addressing violence and promoting positive health outcomes.

Perception of Peer Condom Use Buffers the Associations Between HIV Knowledge, Self-efficacy, and Condom-Use Intention Among Adolescents: a Moderated Mediation Model

A better understanding of the complex relationships between HIV knowledge, self-efficacy, perception of peer condom use, and condom-use intention is needed for improving HIV prevention among adolescents. The study analyzed survey data collected from high school students (N = 1970) in the Bahamas. Mediation and moderated mediation modeling analyses were used for data analysis. Results showed that self-efficacy mediated the association between HIV knowledge and condom-use intention. Perception of peer condom use moderated the mediation model by modifying the HIV knowledge-self-efficacy and self-efficacy-condom-use intention associations among males, but not for females. Findings of the study suggest the significant impact of perception of peer condom use in competition with HIV knowledge and self-efficacy in promoting condom use. Effective intervention program may consider targeting the modification of adolescents' perception of peer condom use to promote condom use among adolescents.

Exploring male condom use among women in South Africa: a review of the literature

The male condom is the most cost-effective method for prevention of HIV and other sexually transmitted infections (STIs), yet in high-burden countries, promotion of its use remains difficult to achieve, especially among high-risk individuals. This review reports on women's perspectives of male condom use and identifies outcome measures that will assist in understanding barriers to male condom use in a South African setting. The Boolean search method was used to retrieve literature, from which 18 studies met the inclusion criteria. The use of the male condom was generally low and inconsistent. Use was higher among women who engaged in transactional sex. Most women had difficulty in negotiating condom use with their partners, particularly if they were in male-dominated relationships or were financially dependent on their partner. Women with higher education levels were able to negotiate use more easily. Interventions for assertive negotiation skills were useful. However, the stigma of infidelity and HIV infection are barriers to condom use. Incorrect use further reduces protection. This review emphasises that women are a vulnerable group who are not always able to control their own protection. Further implementation of the health policies promoting interventions for condom use are required to assist women in taking control of their own protection. Intervention measures should be adapted to include the male population so that they understand and accept condom use. Education to address unequal gender dynamics within relationships is also essential. Much work is required to make women feel less vulnerable in their relationships.

Cultural Consensus Modeling to Understand South African Adolescent Girls' Attitudes, Awareness, and Uptake of Dual Protection Strategies

PURPOSE

This study used cultural consensus modeling to elucidate culturally relevant factors associated with dual protection use (strategies to prevent both pregnancy and sexually transmitted infection [STI]/HIV) among South African adolescent girls aged 14-17 years.

METHODS

In Phase 1, participants (N = 50) completed a free-listing survey assessing pregnancy and STI/HIV methods used by peers. In Phase 2, participants (N = 100) completed a rating survey to examine perceived peer acceptability of Phase 1 pregnancy and STI/HIV prevention methods. In Phase 3, qualitative individual interviews (N = 25) gathered in-depth information regarding the cultural acceptability of pregnancy and STI/HIV prevention strategies. In Phase 4, participants (N = 300) completed the Phase 2 rating survey for individual beliefs regarding the acceptability of pregnancy and STI/HIV prevention methods.

RESULTS

In Phase 1, 41 pregnancy and 29 STI/HIV prevention strategies, along with 16 factors influencing pregnancy prevention method acceptability were endorsed; male condoms were the most commonly endorsed pregnancy and STI/HIV prevention method. In Phase 2, using cultural consensus analysis, participants were consistent in the perceived acceptability of pregnancy and STI/HIV prevention methods (73.4% variance accounted for in single cultural model). In Phase 3, qualitative findings provided in-depth information regarding factors influencing commonly used pregnancy (e.g., injectable contraception) and STI/HIV (e.g., condoms) prevention methods. In Phase 4, a single cultural model was identified (56.3% variance accounted for), with similar acceptability ratings as Phase 2.

CONCLUSIONS

A singular cultural model of pregnancy and STI/HIV prevention method acceptability was observed, with little awareness of dual protection. The findings highlight cultural factors for future culturally tailored dual protection interventions for South African adolescent girls.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

TRIAL REGISTRATION

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Sexual Relationship Power and Periconception HIV-Risk Behavior Among HIV-Infected Men in Serodifferent Relationships

Gender norms affect HIV risk within serodifferent partnerships. We assessed how the sexual relationship power described by men living with HIV (MLWH) associates with periconception HIV-transmission risk behavior. Quantitative surveys were conducted with 82 MLWH reporting a recent pregnancy with an HIV-negative or unknown-serostatus partner in KwaZulu-Natal, South Africa. Surveys assessed decision-making dominance (DMD) using the Pulerwitz et al. sexual relationship power scale; partnership characteristics; and HIV-risk behaviors. Multivariable logistic regression models evaluated associations between DMD score and HIV-risk behaviors. Higher male decision-making dominance was associated with non-disclosure of HIV-serostatus to pregnancy partner (aRR 2.00, 95% CI 1.52, 2.64), not knowing partner's HIV-serostatus (aRR 1.64, 95% CI 1.27, 2.13), condomless sex since pregnancy (aRR 1.92, 95% CI 1.08, 3.43), and concurrent relationships (aRR 1.50, 95% CI 1.20, 1.88). Efforts to minimize periconception HIV-risk behavior must address gender norms and power inequities.

Associations Between Lifetime Traumatic Experiences and HIV-Risk Behaviors Among Young Men Living in Informal Settlements in South Africa: A Cross-Sectional Analysis and Structural Equation Model

Supplemental Digital Content is Available in the Text.

Background:

Qualitative research emphasizes men's experiences of trauma increase HIV risk. We seek to understand associations between experience of traumatic events and HIV-risk behaviors among heterosexual men in 2 trials in urban informal settlements in South Africa.

Methods:

Cross-sectional surveys among men in Johannesburg and Durban, South Africa, enrolled in intervention trials. Adjusted logistic regression and structural equation modeling assessed associations between men's experiences of poverty and traumatic events, and HIV-risk behaviors (inconsistent condom use, transactional sex, and number of sex partners). We explored mediated pathways from trauma to HIV risk through mental health and alcohol, and gender attitudes.

Results:

Among 2394 men, in adjusted logistic regression, transactional sex and 4 or more sex partners were associated with witnessing the murder of a family member, witnessing a murder of a stranger, experiencing excessive pain, been kidnapped, and witnessing a rape. More consistent condom use was associated with witnessing the murder of a family member, being kidnapped, and witnessing a rape. In 3 separate structural equation modeling pathways were consistent, trauma directly increased transactional sex, and past year sexual partners, and increased consistent condom use. Risk was increased through mental health pathways, and gender inequitable attitudes and practices.

Conclusion:

Men's HIV-risk behaviors in this population emerge at the confluence of poverty, traumatic experiences, and gender inequalities. Effective HIV-prevention interventions needs to reduce men's experiences of poverty and trauma, transform gender norms, and reduce the mental health impact of trauma.

Measuring sexual relationship power equity among young women and young men South Africa: Implications for gender-transformative programming

INTRODUCTION

Measures used to assess equitable relationship dynamics, including the sexual relationship power scale (SRPS) have previously been associated with lower HIV-risk among young women, and reduced perpetration of intimate partner violence among men. However, few studies describe how the SRPS has been adapted and validated for use within global youth sexual health studies. We examined gender-specific psychometric properties, reliability, and validity of a SRPS used within a South African youth-engaged cohort study.

METHODS

Young men and women (16-24 years) enrolled in community-based cohorts in Durban and Soweto (2014-2016) reporting a primary partner at 6-month follow-up completed a 13-item (strongly agree/agree/disagree/strongly disagree) South African adaptation of Pulerwitz's SRPS (range 13-52, higher scores indicating greater sexual relationship power [SRP] equity). SRPS modifications were made using gender-specific exploratory factor analyses (EFAs), removing items with factor loadings <0.3. Cronbach alphas were conducted for full and modified scales by gender. Using modified scales, unadjusted and adjusted regression models examined associations between 1. relevant socio-demographic and relationship determinants and SRP equity, and 2. SRP equity and sexual relationship related outcomes. All models adjusted for education, age, site, and current employment.

RESULTS

235 sexually-active youth (66% women, median age = 20) were included. Mean scores across all 13 scale items were 2.71 (SD 0.30) for women and 2.70 (SD 0.4) for men. Scale Cronbach's alphas were 0.63 for women and 0.64 for men. EFAs resulted in two gender-specific single-factor SRPS. Modified SRPS Cronbach alphas increased to 0.67 for women (8-items) and 0.70 for men (9-items). After adjusting for age, site and current employment, higher education remained associated with SRP equity across genders. In adjusted models, correlates of SRP equity included primary partnerships that were age-similar (<5 years older) and <2 years in length for women and living in Soweto and younger age for men. Greater SRP equity among women was also independently associated with no recent partner violence.

CONCLUSIONS

Results highlight important gender differences in SRP equity measures and associations, highlighting the critically need for future research to examine gendered constructions of SRP equity in order to accurately develop, validate and use appropriate measures within quantitative surveys.

Factors associated with consistent condom use: a cross-sectional survey of two Nigerian universities

Background

Consistent condom use is central to the prevention of transmission of human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs), especially among young adults. This study drew from a cross-sectional survey of two Nigerian universities to determine the level of consistent condom use, explored the determinants of condom use consistency and reasons for inconsistent condom use.

Methods

We adopted a descriptive cross-sectional design, which involves the recruitment of 800 male and female students using stratified random sampling. Adjusted and unadjusted logistic regression models were used to examine the factors associated with consistent condom use among a final sample of 498 students who engaged in sex in the last year preceding the study.

Results

Only 38.6% of sexually active participants (n = 498) used condoms consistently in the previous year. High condom self-efficacy score (AOR: 2.40; 95% CI: 1.58–3.64), discussion of HIV/STIs with sexual partner (AOR: 1.91; 95%CI: 1.29–2.83), knowing partner’s HIV status (AOR: 1.48; 95% CI: 1.02–2.16), being students of university located in a high HIV prevalence area (AOR: 2.86; 95% CI: 1.92–4.28) and engaging in sex with only steady partner (AOR: 1.74; 95% CI: 1.17–2.60) were associated with a higher odds of consistent condom use. Trust, unavailability of condoms, dislike of condoms and a perception that condoms reduced sexual pleasure were the main reasons for inconsistent use of condoms.

Conclusion

The study found a low level of consistent condom use among study participants. Counselling young adults in Nigeria on condom self-efficacy, providing condoms on campuses and encouraging the discussion of sexually transmitted infections with sexual partners are central to improving the level of consistent condom use among Nigerian university students.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7543-1) contains supplementary material, which is available to authorized users.

Contextual drivers of HIV risk among young African women

INTRODUCTION

Significant progress has been made in the African HIV pandemic; however, the pace of incidence decline has slowed or stalled in many East and Southern African countries, especially among young women. This stall is worrying because many countries have burgeoning youth populations. There is an important window of opportunity to halt the epidemic as well as the potential for millions more infections if primary prevention efforts are not strengthened.

DISCUSSION

Many hyper-endemic settings have been exposed to numerous interventions; however, HIV incidence among young women has remained high. In this paper, we characterize the intervention context and examine how it can be strategically utilized to maximize HIV prevention interventions among young women. We begin by examining how contextual dynamics drive HIV risk. We illustrate how epidemiological contexts, gendered normative and economic contexts, and environmental contexts work synergistically to make young women especially vulnerable to HIV infection. We then examine how these contexts can undermine HIV prevention interventions. Finally, we discuss the importance of fully mapping out the intervention context to enhance the effectiveness of HIV prevention interventions.

CONCLUSIONS

Understanding an intervention context, and how its features work together to amplify young women's risk in hyper-endemic settings can contribute to sustained momentum in reducing HIV incidence among young women and help to limit the reach of the HIV pandemic into new generations of Africans.

Sociodemographic characteristics, sexual behaviour and knowledge about cervical cancer prevention as risk factors for high-risk human papillomavirus infection in Arkhangelsk, North-West Russia

While sociodemographic predictors of cervical cancer (CC) are well understood, predictors of high-risk (HR) human papillomavirus (HPV) infection have not been fully elucidated. This study explored the HR-HPV infection positivity in relation to sociodemographic, sexual behavior characteristics and knowledge about HPV and CC prevention among women who visited the Arkhangelsk clinical maternity hospital named after Samoylova, Russia. This cross-sectional study was conducted in the city of Arkhangelsk, Northwest Russia. Women who consulted a gynecologist for any reason between 1 January 2015 and 30 April 2015 were residents of Arkhangelsk, 25-65 years of age were included. The Mann-Whitney and Pearson's χ² tests were used. To determine the HR-HPV status, we used the Amplisens HPV-DNA test. We used a questionnaire to collect the information on sociodemographic factors. Logistic regression was applied. The prevalence of HR-HPV infection was 16.7% (n = 50). HR-HPV infection was more prevalent in younger women, cohabiting, nulliparae, smokers, having had over three sexual partners and early age of sexual debut. The odds of having a positive HR-HPV status increased by 25% with an annual decrease in the age of sexual debut. Moreover women with one child or more were less likely to have positive HR-HPV status.

Feeling Under Pressure: Perspectives of the Meaning of Love and Sexual Relationships Amongst Young Men in KwaZulu-Natal Province, South Africa

This study aimed to explore perspectives on the meaning of love and sexual relations amongst young men in KwaZulu-Natal province of South Africa. Gaining insights into these perspectives will help to understand the sexual behaviors of these young men better and to eventually develop more effective HIV prevention interventions. Focus group discussions were conducted in two study areas using a predetermined semistructured discussion guide. The findings indicate that the phenomenon of romantic relationship try-outs together with the idea of "feeling under pressure" to propose love to more than one woman seem to be accepted practices that often lead to multiple concurrent sexual partners and therefore potentially risky sexual behaviors. The fear of impregnating a woman is seen to be of a more significant concern than acquiring a sexually transmitted infection due to the stigma and embarrassment associated with pregnancy outside marriage. Given these findings, it is recommended that future studies investigate perspectives on sexuality and reproductive health in male populations in great detail prior to the development of behavioral change interventions because failure to do so may hamper well-intended but poorly targeted health interventions.

Adapting the Risk Environment Framework to Understand Substance Use, Gender-Based Violence, and HIV Risk Behaviors Among Female Sex Workers in Tanzania

Female sex workers (FSWs) in sub-Saharan Africa are disproportionately affected by HIV and gender-based violence (GBV). Substance use overlaps with these co-occurring epidemics to further increase FSWs' risk for negative health outcomes. We explored the relationship between substance use, GBV, and consistent condom use utilizing baseline data from a cohort of 496 FSWs in Tanzania. Results demonstrate high levels of alcohol use and GBV, and low levels of consistent condom use. Frequent intoxication during sex work was associated with increased odds of recent GBV (aOR 1.64, 95% CI 1.07, 2.49; p value 0.02) and reduced odds of consistent condom use with clients (aOR 0.58, 95% CI 0.37, 0.92; p-value 0.02). We adapt the risk environment framework to contextualize our findings in the social and structural context and to gain insight into intervention approaches to address the intersecting challenges of substance use, GBV, and HIV among FSWs in Tanzania and similar settings.

Associations with Unprotected Sexual Behavior Among HIV-Infected Drinkers in Western Kenya

Approximately 71% of HIV-infected individuals live in sub-Saharan Africa. Alcohol use increases unprotected sex, which can lead to HIV transmission. Little research examines risky sex among HIV-infected individuals in East Africa who are not sex workers. The study purpose was to examine associations with unprotected sex in a high-risk sample of 507 HIV-infected sexually active drinkers in western Kenya. They were enrolled in a trial to reduce alcohol use. Past-month baseline alcohol use and sexual behavior were assessed using the Timeline Followback. A zero-inflated negative binomial model examined associations with occurrence and frequency of unprotected sex. Results showed heavy drinking days were significantly associated with unprotected sex occurrence across gender, and with unprotected sex frequency among women. Among women, transactional sex, alcohol-related sexual expectations, condom use self-efficacy, drinking-and-protected-sex days and age were associated with unprotected sex occurrence while alcohol-related sexual expectations, depressive symptoms and condom use self-efficacy were associated with unprotected sex frequency. Among men, alcohol-related sexual expectations, condom use self-efficacy, and age were associated with unprotected sex occurrence, while drinking-and-protected-sex days were associated with unprotected sex occurrence and frequency. Findings suggest robust relationships between heavy drinking and unprotected sex. Further research is needed elucidating the temporal relationships between drinking and unprotected sex in this population.

Transactional sex and incident HIV infection in a cohort of young women from rural South Africa

Objective:

In sub-Saharan Africa, young women who engage in transactional sex (the exchange of sex for money or gifts) with a male partner show an elevated risk of prevalent HIV infection. We analyse longitudinal data to estimate the association between transactional sex and HIV incidence.

Design:

We used longitudinal data from a cohort of 2362 HIV-negative young women (aged 13–20 years) enrolled in a randomized controlled trial in rural, South Africa who were followed for up to four visits over 6 years.

Methods:

The effect of transactional sex on incident HIV was analysed using stratified Cox proportional hazards models and cumulative incidence curves. Risk ratios were estimated using log-binomial models to compare the effects across visits.

Results:

HIV incidence was higher for young women that reported transactional sex (hazard ratio 1.59, 95% confidence interval 1.02–2.19), particularly when money and/or gifts were received frequently (at least weekly) (hazard ratio 2.71, 95% confidence interval 1.44–5.12). We also find that effects were much stronger during the main trial and dissipate at the postintervention visit, despite an increase in both transactional sex and HIV.

Conclusion:

Transactional sex elevates the risk of HIV acquisition among young women, especially when it involves frequent exchanges of money and/or gifts. However, the effect was attenuated after the main trial, possibly due to the changing nature of transactional sex and sexual partners as women age. These findings suggest that reducing transactional sex among young women, especially during adolescence, is important for HIV prevention.

Sexual Self-Efficacy and Gender: A Review of Condom Use and Sexual Negotiation Among Young Men and Women in Sub-Saharan Africa

Sexual self-efficacy (SSE), one's perceived control of or confidence in the ability to perform a given sexual outcome, predicts sexual behavior; however, important questions remain regarding whether gender modifies observed associations. In a comprehensive review of peer-reviewed HIV-prevention literature focusing on youth (ages 10 to 25) in sub-Saharan Africa, we measured and assessed the influence of SSE on condom use and sexual refusal, overall and by gender. Our results, after reviewing 63 publications, show that SSE is inconsistently measured. Most studies measured condom use self-efficacy (CUSE) (96.8%) and/or sexual refusal self-efficacy (SRSE) (63.5%). On average, young men had higher CUSE than young women, while young women had higher SRSE than young men. While cross-sectional studies reported an association between high SSE and sexual behaviors, this association was not observed in interventions, particularly among young women who face a disproportionate risk of HIV acquisition. In all, 25% of intervention studies demonstrated that fostering CUSE increased condom use among young men only, and one of two studies demonstrated that higher SRSE led to reduced frequency of sexual activity for both men and women. Future research and HIV-prevention interventions must be gender targeted, consider improving CUSE for young men, and move beyond limited individual-level sexual behavior change frameworks.

Gender differences in prevalence and correlates of high sexual self-efficacy among adolescents in Soweto, South Africa: implications for gender-sensitive research and programming

Sexual self-efficacy (SSE) - one's confidence in their ability to perform given sexual behaviours, has been shown to predict adolescents' HIV-prevention practices (e.g., Condom use). Few studies within sub-Saharan Africa, where HIV incidence and prevalence disproportionately affects young women, have examined gendered differences in SSE. We used multivariable logistic regression to identify correlates of high-SSE separately among adolescent men and women (aged 14-19) in Soweto, South Africa using a previously validated SSE scale (high-SSE [>3/6 items]; study-alpha = 0.75). SSE scale items assessed self-efficacy related to sexual refusal and condom use. Adolescent women were significantly more likely to report high-SSE than adolescent men (72.3% versus 49.5%; p < 0.01). High-SSE among adolescent men was associated with more positive beliefs about sexual relationships and negatively associated with probable depression. High-SSE among adolescent women was associated with increased HIV knowledge, more positive beliefs about condom use and sexual relationships, having an adult in the home, and negatively associated with being an older adolescent (16-17 versus ≤15), and ever experiencing physical violence. Differences in prevalence and correlates of SSE among adolescent men and women in South Africa highlight important areas for gender-sensitive interventions. Targeted efforts to reduce negative sexual beliefs, improve HIV knowledge and mental well-being may improve SSE and thus the uptake of HIV-prevention practices among adolescent men. For adolescent women, findings indicate programming should move beyond individual-levels determinants of behaviour to focus on improving enabling environments (e.g., Reduced violence and improved family relationships) in which sexual agency can be enacted.

Cross-sectional study of female sex workers in Soweto, South Africa: Factors associated with HIV infection

INTRODUCTION

In South Africa, the rate of HIV in the sex worker (SW) population is exceedingly high, but critical gaps exist in our understanding of SWs and the factors that make them vulnerable to HIV. This study aimed to estimate HIV prevalence among female sex workers (FSWs) in Soweto, South Africa, and to describe their sexual behavior and other factors associated with HIV infection.

METHODS

A cross-sectional, respondent-driven sampling (RDS) recruitment methodology was used to enroll 508 FSWs based in Soweto. Data were collected using a survey instrument, followed by two HIV rapid tests. Raw and RDS adjusted data were analyzed using a chi-squared test of association and multivariate logistic regression to show factors associated with HIV infection.

FINDINGS

HIV prevalence among FSWs was 53.6% (95% CI 47.5-59.9). FSWs were almost exclusively based in taverns (85.6%) and hostels (52.0%). Less than a quarter (24.4%) were under 25 years of age. Non-partner violence was reported by 55.5%, 59.6% of whom were HIV-infected. Advancing age, incomplete secondary schooling, migrancy and multiple clients increased the likelihood of HIV acquisition: >30 years of age was associated with a 4.9 times (95% CI 2.6-9.3) increased likelihood of HIV; incomplete secondary schooling almost tripled the likelihood (AOR 2.8, 95% CI 1.6-5.0); being born outside of the Gauteng province increased the likelihood of HIV 2.3 times (95% CI 1.3-4.0); and having more than five clients per day almost doubled the likelihood (AOR 1.9, 95% CI 1.1-3.2).

CONCLUSION

Our findings highlight the extreme vulnerability of FSWs to HIV. Advancing age, limited education and multiple clients were risk factors associated with HIV, strongly driven by a combination of structural, biological and behavioral determinants. Evidence suggests that interventions need to be carefully tailored to the varying profiles of SW populations across South Africa. Soweto could be considered a microcosm of South Africa in terms of the epidemic of violence and HIV experienced by the SW population, which is influenced by factors often beyond an individual level of control. While describing a hitherto largely undocumented population of FSWs, our findings confirm the urgent need to scale up innovative HIV prevention and treatment programs for this population.

Partner Relationships and Injection Sharing Practices among Rural Appalachian Women

BACKGROUND

The role of relationships in initiating and maintaining women's risk behaviors has been established. However, understanding factors that may underlie partner relationships and women's risky drug use, particularly in rural contexts, is limited. This study is the first to examine the association between injecting partners and women's risky injection practices as a function of relationship power perception.

METHODS

Female participants were recruited from three rural jails in the Appalachian region. Women were selected randomly, provided informed consent, and screened for study eligibility criteria. This cross-sectional analysis focuses on women who inject drugs during the year before entering jail (n = 199).

MAIN FINDINGS

Approximately three-quarters (76%) reported having a recent main male sexual partner with a history of injection drug use. Although having a risky partner independently increased the likelihood of women reporting shared injection practices, perceptions of relationship power significantly moderated the effect on shared needle (adjusted odds ratio, 0.02; 95% CI, 0.003-0.23; p = .001) and shared works (adjusted odds ratio, 0.17; 95% CI, 0.03-0.95; p = .04) use.

CONCLUSIONS

This interaction indicated that, for women who inject drugs with a recent injecting male partner, greater perception of relationship power was associated with a decreased likelihood of shared injection practices. Implications for clinical assessment and intervention are discussed.

Young women's perceptions of transactional sex and sexual agency: a qualitative study in the context of rural South Africa

BACKGROUND

Evidence shows that HIV prevalence among young women in sub-Saharan Africa increases almost five-fold between ages 15 and 24, with almost a quarter of young women infected by their early-to mid-20s. Transactional sex or material exchange for sex is a relationship dynamic that has been shown to have an association with HIV infection.

METHODS

Using five focus group discussions and 19 in-depth interviews with young women enrolled in the HPTN 068 conditional cash transfer trial (2011-2015), this qualitative study explores young women's perceptions of transactional sex within the structural and cultural context of rural South Africa. The analysis also considers the degree to which young women perceive themselves as active agents in such relationships and whether they recognise a link between transactional sex and HIV risk.

RESULTS

Young women believe that securing their own financial resources will ultimately improve their bargaining position in their sexual relationships, and open doors to a more financially independent future. Findings suggest there is a nuanced relationship between sex, love and gifts: money has symbolic meaning, and money transfers, when framed as gifts, indicates a young woman's value and commitment from the man. This illustrates the complexity of transactional sex; the way it is positioned in the HIV literature ignores that "exchanges" serve as fulcrums around which romantic relationships are organised. Finally, young women express agency in their choice of partner, but their agency weakens once they are in a relationship characterised by exchange, which may undermine their ability to translate perceived agency into STI and HIV risk reduction efforts.

CONCLUSIONS

This research underscores the need to recognise that transactional sex is embedded in adolescent romantic relationships, but that certain aspects make young women particularly vulnerable to HIV. This is especially true in situations of restricted choice and circumscribed employment opportunities. HIV prevention educational programmes could be coupled with income generation trainings, in order to leverage youth resilience and protective skills within the confines of difficult economic and social circumstances. This would provide young women with the knowledge and means to more successfully navigate safer sexual relationships.

Transactional sex among young women in rural South Africa: prevalence, mediators and association with HIV infection

INTRODUCTION

Young adolescent women in sub-Saharan Africa are three to four times more likely to be HIV-positive than boys or men. One of the relationship dynamics that is likely to be associated with young women's increased vulnerability to HIV is transactional sex. There are a range of HIV-related risk behaviours that may drive this vulnerability. However, to date, limited epidemiological data exist on the role of transactional sex in increasing HIV acquisition, especially among young women in sub-Saharan Africa. Our paper presents data on the prevalence of self-reported engagement in transactional sex and explores whether transactional sex is associated with increased risk of HIV infection among a cohort of young, rural, sexually active South African women. We also explore whether this relationship is mediated through certain HIV-related risk behaviours.

METHODS

We analyzed baseline data from a phase III trial of conditional cash transfers for HIV prevention of 693 sexually active, school-going young women aged 13-20 years in rural South Africa. We examined the association between young women's engagement in transactional sex and HIV infection. Transactional sex is defined as a non-commercial, non-marital sexual relationship whereby sex is exchanged for money and/or gifts. We explored whether this relationship is mediated by certain HIV-related risk behaviours. We used logistic and multinomial regression and report unadjusted and adjusted odds ratios with 95% CI.

RESULTS

Overall, 14% (n=97) of sexually active young women reported engaging in transactional sex. Engagement in transactional sex was associated with an increased risk of being HIV-positive (aOR: 2.5, CI: 95% 1.19-5.25, p=0.01). The effect size of this association remained nearly unchanged when adjusted for certain other dimensions of HIV risk that might help explain the underlying pathways for this relationship.

CONCLUSIONS

This study provides quantitative support demonstrating that transactional sex is associated with HIV infection in young women. Even though the specific variables tested do not mediate the relationship, a potential explanation for this association may be that the men with whom young women are having sex belong to networks of sexually connected individuals who are at a "high risk" for HIV infection. The results highlight the importance of structural intervention approaches that can alter the context of young women's HIV risk.

Predictors of consistent condom use among Portuguese women attending family planning clinics

Women account for 30% of all AIDS cases reported to the Health Ministry in Portugal and most infections are acquired through unprotected heterosexual sex with infected partners. This study analyzed socio-demographic and psychosocial predictors of consistent condom use and the role of education as a moderator variable among Portuguese women attending family planning clinics. A cross-sectional study using interviewer-administered fully structured questionnaires was conducted among 767 sexually active women (ages 18-65). Logistic regression analyses were used to explore the association between consistent condom use and the predictor variables. Overall, 78.7% of the women were inconsistent condom users. The results showed that consistent condom use was predicted by marital status (being not married), having greater perceptions of condom negotiation self-efficacy, having preparatory safer sexual behaviors, and not using condoms only when practicing abstinence. Living with a partner and having lack of risk perception significantly predicted inconsistent condom use. Less educated women were less likely to use condoms even when they perceive being at risk. The full model explained 53% of the variance in consistent condom use. This study emphasizes the need for implementing effective prevention interventions in this population showing the importance of taking education into consideration.

Self-determination and gender-power relations as predictors of condom use self-efficacy among South African women

This article identifies correlates of condom use self-efficacy using concepts from self-determination theory and gender–power measures. A cross-section of Xhosa-speaking women (n = 238) from Eastern Cape, South Africa, was used to conduct bivariate correlations and multivariate linear regression analyses. Gender equality beliefs and HIV knowledge were positively associated with condom use self-efficacy generally and in risky situations. Condom use self-efficacy generally was also positively associated with power balance attitudes, negative beliefs about intimate partner violence, and positive growth perspective, while the association with hopeless personal perspective was negative. Surprisingly, lack of social support was positively associated with condom use self-efficacy in risky situations. The predictors of condom use self-efficacy identified in this study that may serve as change objectives for future sexual health promotion interventions.

Correlates of inconsistent condom use among youth aged 18-24 years in South Africa

This paper examines the correlates of inconsistent condom use with most recent sexual partner among sexually experienced youth (N = 2 138) in South Africa. A cross-sectional population based survey with youth aged 18 to 24 years was conducted in 4 provinces (Eastern Cape, Gauteng, KwaZulu-Natal and Mpumalanga). More women than men (57.7% vs. 25.8%) reported inconsistent condom use with their most recent partner. Multivariate analysis indicated that for males, not having talked with a partner about condoms in the past 12 months, having 2 or more sexual partners in the past 12 months, having ever had a transactional sex partner and alcohol use before sex in the past 3 months were associated with inconsistent condom use with their most recent sexual partner. In females multivariate analysis showed that lack of self-efficacy, not having talked with a partner about condoms in the past 12 months, having ever had or been subjected to forced sex and hazardous or harmful alcohol use were found to be associated with inconsistent condom use with their most recent sexual partner in multivariate analysis.

Individual, Interpersonal, and Structural Power: Associations With Condom Use in a Sample of Young Adult Latinos

Interviews were conducted with 480 sexually active Latino young adults from four rural counties in Oregon. We examined relationships between three levels of power (individual, interpersonal, and structural) and consistent condom use. Condom use self-efficacy and sexual decision-making, examples of individual and interpersonal measures of power, respectively, were associated with increased odds of consistent condom use among both men and women. Among men only, increasing relationship control, an interpersonal measure of power, was associated with lower odds of consistent condom use. Among women only, increasing medical mistrust, a structural measure of power, was associated with increased odds of consistent condom use.

A systematic review of the psychometric properties of the Sexual Relationship Power Scale in HIV/AIDS research

The Sexual Relationship Power Scale (SRPS) was developed over a decade ago to address the lack of reliable and valid measures of relationship power in social, behavioral and medical research. The SRPS and its two subscales (relationship control [RC], decision-making dominance [DMD]) have been used extensively in the field of HIV prevention and sexual risk behavior. We performed a systematic review of the psychometric properties of the SRPS and subscales as reported in the HIV/AIDS literature from 2000 to 2012. A total of 54 published articles were identified, which reported reliability or construct validity estimates of the scales. Description of the psychometric properties of the SRPS and subscales is reported according to study population, and several cross-population trends were identified. In general, the SRPS and RC subscale exhibited sound psychometric properties across multiple study populations and research settings. By contrast, the DMD subscale had relatively weak psychometric properties, especially when used with specific populations and research settings. Factors that influenced the psychometric properties of the various scales and subscales included the study population, mean age of the sample, number of items retained in the scale, and modifications to the original scales. We conclude with recommendations for (1) the application and use of the SRPS and subscales, (2) reporting of psychometric properties of the scales in the literature, and (3) areas for future research.

Alcohol use, sexual relationship power, and unprotected sex among patrons in bars and taverns in rural areas of North West province, South Africa

We examined the relative importance of alcohol consumption and sexual relationship power (SRP) in predicting unprotected sex among 406 bar patrons in North West province, South Africa. We assessed participants' demographic characteristics, alcohol consumption, SRP, and number of unprotected sexual episodes in the past 6 months. In correlational analyses, alcohol consumption was significantly associated with frequency of unprotected sex for both males and females. SRP was significantly associated with frequency of unprotected sex for males and marginally associated for females. In multivariate regression analyses, alcohol consumption was significantly associated with frequency of unprotected sex for both males and females. SRP's association was marginally significant for females and not significant for males. Alcohol consumption is more strongly associated with unprotected sex than is SRP among bar patrons. Combination HIV prevention approaches to curb problem drinking and increase condom accessibility, and regular and effective use are needed in tavern settings. SRP needs further examination among tavern populations.

Sexual risk reduction interventions for HIV prevention among South African youth: a meta-analytic review

OBJECTIVES

To examine the efficacy of sexual risk reduction interventions among South African youth.

METHODS

Electronic databases were searched to identify studies published between 2007 and early 2013. Studies were eligible if they (1) targeted youth age 9-26, (2) evaluated sexual risk reduction interventions and (3) reported at least one behavioral outcome. Independent raters coded study characteristics, and intervention content. Weighted mean effect sizes were calculated; positive effect sizes indicated less sexual risk behavior and incident STIs.

RESULTS

Ten studies (k = 11; N = 22,788; 54% female; 79% Black-African) were included. Compared to controls, interventions were successful at delaying sexual intercourse and, among sexually active youth, at increasing condom use. A single study found reductions in the incidence of herpes simplex virus-2, but not HIV.

CONCLUSIONS

Implementing behavioral interventions to delay sexual debut and improve condom use can help to reduce the transmission of HIV among South African youth.

The association between ethnic identity and condom use among young men in the Eastern Cape Province, South Africa

This article reports on the association between ethnic identity and condom use among Black African men in the rural areas of the Eastern Cape Province, South Africa. Individual face-to-face structured interviews were conducted by trained community research assistants among 1,656 men who had undergone traditional initiation and male circumcision. Logistic regression analyses were used to explore the association between two components of ethnic identity (cultural affiliation and cultural alienation) and condom use. Overall, 49.2 % of the participants reported using condoms consistently and, of these users, 66.4 % used them correctly. Logistic regression adjusting for age, employment status, education level, and nation of origin showed that participants who expressed high as opposed to low cultural affiliation were significantly more likely to use condoms consistently and correctly when having sex, especially if they reported to have more than one sexual partner. Cultural alienation was negatively related with consistent condom use, whereas its association with correct use was unclear. The findings of this study suggest that positively emphasizing the ethnic identity of African black men may promote condom use.

Intimate partner violence against female sex workers in Mombasa, Kenya

Female sex workers are known to be at risk of intimate partner violence (IPV) from numerous sources including clients, pimps, boyfriends and husbands. Better understanding the factors associated with IPV in this population will enhance prevention efforts. This work examines baseline survey data collected as part of a randomised controlled trial for an alcohol-harm reduction intervention. The study sample included 619 sex workers. IPV was common in this sample, with 78.7% of women reporting any IPV in the last 30 days. Multivariate logistic regression results indicated that supporting one to two other people, experiencing child abuse, witnessing mother abuse, and greater alcohol consumption were risk factors for IPV in our sample. Women who frequented Population, Health and Integrated Assistance (APHIA) II drop-in centres located along transport corridors were also at greater risk of recent IPV, as compared with those who frequented other drop-in centres. Only one protective effect was identified in this study: condom use at last sex with a non-paying partner was associated with less recent IPV. Health programmes for women sex workers in Mombasa and elsewhere need to expand beyond HIV prevention - they need to incorporate information on violence prevention and treatment referrals, as well as information on alcohol harm reduction.

Informing HIV prevention efforts targeting Liberian youth: a study using the PLACE method in Liberia

Background

Preventing HIV infection among young people is a priority for the Liberian government. Data on the young people in Liberia are scarce but needed to guide HIV programming efforts.

Methods

We used the Priorities for Local AIDS Control Efforts (PLACE) method to gather information on risk behaviors that young people (ages 14 to 24) engage in or are exposed to that increase their vulnerability for HIV infection. Community informants identified 240 unique venues of which 150 were visited and verified by research staff. 89 of the 150 venues comprised our sampling frame and 571 females and 548 males were interviewed in 50 venues using a behavioral survey.

Results

Ninety-one percent of females and 86% of males reported being sexually active. 56% of females and 47% of males reported they initiated sexual activity before the age of 15. Among the sexually active females, 71% reported they had received money or a gift for sex and 56% of males reported they had given money or goods for sex. 20% of females and 6% males reported that their first sexual encounter was forced and 15% of females and 6% of males reported they had been forced to have sex in the past year. Multiple partnerships were common among both sexes with 81% females and 76% males reporting one or more sex partners in the past four weeks. Less than 1% reported having experiences with injecting drugs and only 1% of males reporting have sex with men. While knowledge of HIV/AIDS was high, prevention behaviors including HIV testing and condom use were low.

Conclusion

Youth-focused HIV efforts in Liberia need to address transactional sex and multiple and concurrent partnerships. HIV prevention interventions should include efforts to meet the economic needs of youth.

Masculinities and condom use patterns among young rural South Africa men: a cross-sectional baseline survey

BACKGROUND

Notions of ideal manhood in South Africa are potentially prescriptive of male sexuality thus accounting for the behaviors which may lead to men being at greater HIV risk. We tested the hypothesis that gender and relationship constructs are associated with condom use among young men living in rural South Africa.

METHODS

1219 men aged 15-26 years completed a cross-sectional baseline survey from an IsiXhosa questionnaire asking about sexual behaviour and relationships. Univariate and bivariate analyses described condom use patterns and explanatory variables, and multinomial regression modeling assessed the factors associated with inconsistent versus consistent and non-condom use.

RESULTS

47.7% of men never used condoms, when 36.9% were inconsistent and 15.4% were consistent with any partner in the past year. Condom use patterns differed in association with gender relations attitudes: never users were significantly more conservative than inconsistent or consistent users. Three gender positions emerged indicating that inconsistent users were most physically/sexually violent and sexually risky; never users had more conservative gender attitudes but were less violent and sexually risky; and consistent users were less conservative, less violent and sexually risky with notably fewer sexual partners than inconsistent users.

CONCLUSIONS

The confluence of conservative gender attitudes, perpetration of violence against women and sexual risk taking distinguished inconsistent condom users as the most risky compared to never condom users, and rendered inconsistent use one of the basic negative attributes of dominant masculinities in the Eastern Cape, South Africa. This finding is important for the design of HIV prevention and gender equity interventions and emphasizes the need for a wider roll-out of interventions that promote progressive and healthy masculine practices in the country.

Barriers to condom use among women at risk of HIV/AIDS: a qualitative study from Iran

Background

The growing trend of women infected with HIV through sexual transmission is alarming. Factors influencing condom use have not yet been fully identified, especially in countries with conservative cultures and backgrounds. The present study aimed to explore the barriers of condom use in Iranian women at risk of HIV.

Methods

Using the grounded theory methodology, participants’ experiences and their perceptions regarding condom were collected during semi structured in depth interviews. Participants were 22 women, aged 21–49 years, considered to be at risk for HIV, due to their own or their partner’s sexual behaviors. Qualitative analysis of the data was conducted manually and was guided by constant comparative analysis.

Results

Two main barriers, personal and socio-environmental emerged from data analysis. Lack of perceived threat, absence of protective motivation, inadequate knowledge, perceived lack of control, negative attitudes towards condom and misperception were the major personal barriers, while unsupportive environments and cultural norms were the common socio-environmental barriers to condom use among these at risk women.

Conclusions

These critical barriers have to be addressed for implementing effective prevention programs against HIV among populations at risk for HIV.

The sexual behaviour of adolescents in sub-Saharan Africa: patterns and trends from national surveys

OBJECTIVES

To describe the sexual and reproductive behaviour of adolescents in sub-Saharan Africa, particularly 15- to 19-year-olds.

METHODS

 Using DHS/AIS data (2000-2010), nine indicators of adolescent behaviour and one of adult attitudes towards condom education for adolescents were described for 24 countries. Indicators were disaggregated by gender, urban/rural residency and educational status, and time trends were described.

RESULTS

Up to 25% of 15- to 19-year-olds reported sex before age 15; this proportion shrank over time in many countries. In most countries, ≥5% of females reported marriage before age 15, and >20% had commenced childbearing. Early sexual debut and childbearing were more common among the least educated and/or rural females. Reporting of multiple sexual partnerships was more common among males than among females, but decreases over time were more common among males. Urban males and females, and females with higher education, were more likely to report multiple partnerships. Urban youth and those with higher education also reported more condom use. Adult support for condom education for 12- to 14-year-olds has increased over time to 60-65%.

CONCLUSIONS

Many 15- to 19-year-olds are at risk of HIV/STIs and unplanned pregnancies because of multiple partnerships and insufficient condom and other contraceptive use. In many countries, trends are moving in a favourable direction. To better inform prevention programmes in this important area, we recommend routine collection of sexual and reproductive behaviour data for adolescents aged <15 years, expanding the data collected for 15- to 19-year-olds to include detailed information on sexual behaviour within partnerships, and disaggregating data according to sociodemographic variables.

Progress and challenges to male and female condom use in South Africa

South Africa has responded to the sexually transmissible infection and HIV epidemic with a rapid expansion of its national-level public sector condom program. Male condoms are available widely at no cost in the public sector, with expanded access via social marketing and the private sector. The female condom program is one of the largest and best established globally. National surveys show progressive increases in rates of condom use at last sex. However, inconsistent and incorrect condom use and the likelihood that condoms are discontinued in longer-term partnerships are some of the challenges impeding the condom program's successes in the fight against sexually transmissible infections and HIV. This article reviews the current condom program, related guidelines and policies, and the existing data on male and female condom use, including distribution and uptake. We discuss the main challenges to condom use, including both user and service-related issues and finally how these challenges could be addressed.

Associations between depressive symptoms, sexual behaviour and relationship characteristics: a prospective cohort study of young women and men in the Eastern Cape, South Africa

BACKGROUND

Psychological factors are often neglected in HIV research, although psychological distress is common in low- to middle-income countries, such as South Africa. There is a need to deepen our understanding of the role of mental health factors in the HIV epidemic. We set out to investigate whether baseline depressive symptomatology was associated with risky sexual behaviour and relationship characteristics of men and women at baseline, as well as those found 12 months later.

METHODS

We used prospective cohort data from a cluster randomized controlled trial of an HIV prevention intervention in the Eastern Cape Province of South Africa. Our subjects were 1002 female and 976 male volunteers aged 15 to 26. Logistic regression was used to model the cross-sectional and prospective associations between baseline depressive symptomatology, risky sexual behaviors and relationship characteristics. The analysis adjusted for the clustering effect, study design, intervention and several confounding variables.

RESULTS

Prevalence of depressive symptoms was 21.1% among women and 13.6% among men. At baseline, women with depressed symptoms were more likely to report lifetime intimate partner violence (AOR = 2.56, 95% CI 1.89-3.46) and have dated an older partner (AOR = 1.37, 95% CI 1.03-1.83). A year later, baseline depressive symptomatology was associated with transactional sex (AOR = 2.60, 95% CI 1.37, 4.92) and intimate partner violence (AOR = 1.67, 95% CI 1.18-2.36) in the previous 12 months. Men with depressive symptoms were more likely to report ever having had transactional sex (AOR = 1.48, 95% CI 1.01-2.17), intimate partner violence perpetration (AOR = 1.50, 95% CI 0.98-2.28) and perpetration of rape (AOR = 1.81, 95% CI 1.14-2.87). They were less likely to report correct condom use at last sex (AOR = 0.50, 95% CI 0.32-0.78). A year later, baseline depressive symptomatology was associated with failure to use a condom at last sex among men (AOR = 0.60, 95% CI 0.40-0.89).

CONCLUSIONS

Symptoms of depression should be considered as potential markers of increased HIV risk and this association may be causal. HIV prevention needs to encompass promotion of adolescent mental health.

Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention

Research shows that gender power inequity in relationships and intimate partner violence places women at enhanced risk of HIV infection. Men who have been violent towards their partners are more likely to have HIV. Men's behaviours show a clustering of violent and risky sexual practices, suggesting important connections. This paper draws on Raewyn Connell's notion of hegemonic masculinity and reflections on emphasized femininities to argue that these sexual, and male violent, practices are rooted in and flow from cultural ideals of gender identities. The latter enables us to understand why men and women behave as they do, and the emotional and material context within which sexual behaviours are enacted.

In South Africa, while gender identities show diversity, the dominant ideal of black African manhood emphasizes toughness, strength and expression of prodigious sexual success. It is a masculinity women desire; yet it is sexually risky and a barrier to men engaging with HIV treatment. Hegemonically masculine men are expected to be in control of women, and violence may be used to establish this control. Instead of resisting this, the dominant ideal of femininity embraces compliance and tolerance of violent and hurtful behaviour, including infidelity.

The women partners of hegemonically masculine men are at risk of HIV because they lack control of the circumstances of sex during particularly risky encounters. They often present their acquiescence to their partners' behaviour as a trade off made to secure social or material rewards, for this ideal of femininity is upheld, not by violence per se, by a cultural system of sanctions and rewards. Thus, men and women who adopt these gender identities are following ideals with deep roots in social and cultural processes, and thus, they are models of behaviour that may be hard for individuals to critique and in which to exercise choice. Women who are materially and emotionally vulnerable are least able to risk experiencing sanctions or foregoing these rewards and thus are most vulnerable to their men folk.

We argue that the goals of HIV prevention and optimizing of care can best be achieved through change in gender identities, rather than through a focus on individual sexual behaviours.