HIV risk behaviors and the context of sexual coercion in young adults' sexual interactions: results from a diary study in rural South Africa

Sexual Coercion is Associated with HIV Risk Behavior Among Female Waiters in Jimma Town, Southwest Ethiopia

Background

Female waiters are at higher risk of workplace violence including sexual coercion. Even though there are numerous studies on the prevalence of sexual coercion among students, nurses, adolescents, and young pregnant women, studies on the prevalence of sexual coercion among female waiters are limited. Furthermore, there is no evidence existed that show a relationship between sexual coercion and HIV risk behavior in Ethiopia.

Purpose

The purpose of this study was to examine the relationship between sexual coercion and HIV risk behavior among female waiters in Jimma, southwest Ethiopia.

Patients and Methods

We conducted a cross-sectional survey from 1st April to 30, 2018, among 420 female waiters of reproductive age working in the licensed food and drinking establishments in Jimma town. A structured interviewer-administered questionnaire was used to collect data. Statistical analysis was conducted with SPSS version 21 statistical software. A binary logistic regression model was used to determine the association between independent variables and outcome variables.

Results

The lifetime prevalence of sexual coercion among female waiters was 71.4% (95% confidence interval: 67.1-76.8). More than two-thirds (71.6%) of female waiters engaged in HIV-related risk behaviors. Working in the bar (AOR 4.64, 95% CI: 2.15-10.0), being a substance user (AOR 3.37, 95% CI: 1.7-6.7), experiencing sexual coercion (AOR 7.6, 95% CI: 3.8-15.3) were significantly associated with HIV risk behaviors.

Conclusion

A significant number of female waiters experienced sexual coercion and engaged in HIV-risk behaviors. Workplace, substance use, and sexual coercion were significantly associated with HIV risk behavior. As a result, establishments, town health offices, and other stakeholders should work together to safeguard female waiters from the burdens of sexual coercion, HIV risk behavior, and sexually transmitted infections.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence of risk factors for human immunodeficiency virus among women of reproductive age in Sierra Leone: a 2019 nationwide survey

Background and aim

For over 40 years of the HIV/AIDS global epidemic, no effective cure nor vaccine is yet available, making the current control strategies focused on curbing new infections through risk reduction. The study aimed to determine the prevalence of HIV risk factors and their associated socio-demographics among women of reproductive age in Sierra Leone.

Methods

We used weighted data from the Sierra Leone Demographic and Health Survey (SLDHS) of 2019 for 12,005 women aged 15–49 years. Multistage sampling was used to select study participants. Exposure to HIV risk factors was considered if a woman reported at least one of the following; having multiple sexual partners, transactional sex, non-condom use for the unmarried, and having other sexually transmitted infections (STIs). We, then, conducted multivariable logistic regression to explore the associated socio-demographics. All the analyses were done using SPSS (version 25).

Results

Of the 12,005 women, 38.1% (4577/12005) (95% confidence interval (CI) 37.3–39.0) had at least one of the four risk factors. Women of 15 to 19 years (adjusted odds ratio (AOR) = 1.34, 95% CI 1.00–1.80) and 20 to 34 years (AOR = 1.25, 95% CI 1.05–1.49) had more odds of having HIV risk factors compared to those of 35 to 49 years. Urban residents (AOR = 1.49, 95% CI 1.17–1.89) and those from the Northwestern region (AOR = 1.81, 95% CI 1.26–2.60) were also more likely to encounter HIV risk factors compared to their respective counterparts. Moreover, unmarried women (AOR = 111.17, 95% CI 87.55–141.18) and those working (AOR = 1.38, 95% CI 1.14–1.67) also had higher odds of having HIV risk factors, compared to their respective counterparts. Sex of household head and parity were also significant associates.

Conclusions

More than a third of women in Sierra Leone had encountered at least one HIV risk factor, and this was associated with age, place of residence, region, marital status, working status, household head and parity. There is a need for strengthening HIV/AIDS education programs, laws and policies targeting the young, working, unmarried and urban-resident women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07037-7.

Gender Matters: Infusing a Gender Analysis into the "Healthy Development of All Youth" Grand Challenge

The social work grand challenge to ensure healthy youth development necessarily involves a focus on violence prevention, including the prevention of sexual and dating violence during adolescence. The experience of sexual and dating violence is associated with numerous and often long-lasting detrimental mental, physical, and social outcomes, many of which this grand challenge seeks to prevent. Although evidence shows that gender is a critical axis of identity to consider in violence prevention research and practice efforts, gender is not a central lens applied in the field's approach to such issues within this grand challenge. First, this article articulates a rationale for infusing a gender analysis into understanding sexual and dating violence and conceptualizing effective violence prevention strategies. Second, authors describe gender-transformative (GT) approaches to sexual and dating violence prevention, a promising practice for both ensuring the healthy development of youths and reducing violence perpetration by focusing on engaging boys and young men. Third, authors discuss the potential for GT strategies to be used in prevention efforts targeting adolescent social issues more broadly. Last, authors call for practitioners and researchers focused on healthy youth development to apply a gender analysis in their efforts and articulate concrete ways to do so.

Sexual health experiences, knowledge and understanding in low SES female teenagers: A diary approach

INTRODUCTION

Understanding how teenagers think about sexual health and assessing the ways in which they engage with sexual health information are important issues in the development of appropriate sexual health education programmes. Sexual health education programs in the UK are inconsistent and is not possible to assume that teenagers' information needs are being met by such programs. Teenagers often feel uncomfortable discussing sexual health making it difficult to assess teenagers' understanding and engagement with the topic.

METHODS

we used qualitative diaries to explore how thoughts about and exposure to sexual health information features in teenagers' day-to-day lives. Thirty-three low SES female teenagers aged 13 and 14 from schools in the UK kept a daily note of any sexual health related thoughts and feelings, and any sexual health information they encountered.

RESULTS & CONCLUSIONS

Thematic analysis indicated three themes (1) Knowledge gaps and a desire for factual information (2) The social and emotional context of sexual health and (3) limited access to reliable information. Teenagers showed poor understanding of the biological aspects of sexual health and were concerned about the social and emotional context of sexual health. The teenagers' did not actively seek out sexual health information and access to information resources was limited. Although teenagers showed gaps in their knowledge they were curious about sexual health and were open to receiving sexual health information. Being aware of the ways that low SES female teenagers are thinking about sexual health is useful in developing education programs and other resources that will help fill gaps in knowledge and understanding.

HIV Prevention Among Young Women in South Africa: Understanding Multiple Layers of Risk

Despite concerted prevention efforts, young South African women remain at the epicenter of the HIV epidemic. Although these women have grown up in a community powerfully affected by HIV, systematic investigation into how this "second generation" of HIV-affected youth navigates HIV risk is lacking. This study qualitatively explored a complex interplay of factors influencing HIV risk among young pregnant women in KwaZulu-Natal, South Africa. We conducted in-depth interviews with 35 pregnant women (22 HIV-uninfected and 13 HIV-infected) aged 18-21, 18 healthcare providers, and focus groups with 19 community stakeholders. Among the young women, HIV knowledge was high, and many reported taking some action to prevent pregnancy or HIV; however, these efforts were not routinely implemented. Themes related to HIV acquisition risk from all participants were organized using a socioecological framework and revolved around individual and developmental experiences (personal experience with HIV, perceived invincibility), family barriers (lack of adult supervision, pressure to leave school), relational barriers (lack of disclosure and partner communication, "burn out" around attempts to discuss condom use with partners, overdependence on partners), community-level barriers (township environment, lack of structured activities), and social barriers (poverty, HIV-related stigma). Some novel concepts emerged from the data, including an understanding of how overdependence on the romantic relationship may develop. Current HIV prevention efforts, including traditional HIV counseling and testing, condom distribution, and biomedical agents for HIV prevention, are unlikely to be effective without a broader, ecological up-to-date understanding of the evolving, intertwined, and complex constellation of factors that drive HIV risk behavior in this high-risk population.

The Intersection of Men's Sexual Violence Perpetration and Sexual Risk Behavior: A Literature Review

According to the Confluence Model of Sexual Violence, men with a strong impersonal sex orientation (i.e., greater engagement in sexual activities with more casual sexual partners) are at increased risk of perpetrating sexual violence. Research from a variety of countries and samples has supported this proposition, finding that men who perpetrate sexual violence are also more likely to engage in risky sexual behavior. The present article reviews this literature, synthesizing research findings from both psychology and public health domains utilizing both domestic and international samples. In particular, this review focuses on the associations between men's perpetration of sexual violence and their sexual partners, condom use, and sexually transmitted infection status, as well as provides recommendations for future research directions and prevention and intervention programming.

Reproductive consequences of unwanted sexual debut among young adult women from Metro Cebu, Philippines

The circumstances surrounding sexual debut influence subsequent sexual and reproductive outcomes. We analysed longitudinal data from 397 women who participated in the Cebu Longitudinal Health and Nutrition Survey in Cebu, Philippines, to examine associations between unwanted first sex and number of pregnancies, unintended pregnancy, and use of modern contraception. 72% of women reported unwanted first sex. Women whose first sex was unwanted had increased odds of unintended pregnancy compared to women whose first sex was wanted (aOR = 2.2, 95% CI 1.3, 3.6). Nationally representative surveys should include culturally relevant questions about sexual debut to inform public health programmes aimed at improving sexual/reproductive health.

Child Sexual Abuse and Negative Affect as Shared Risk Factors for Sexual Aggression and Sexual HIV Risk Behavior in Heterosexual Men

Previous research has suggested that sexually aggressive behavior and sexual HIV risk behavior are associated. Childhood sexual abuse (CSA) is a well-established risk factor for both types of problematic sexual behavior. Negative affect (i.e., anxiety, depression, and anger) is a less well-studied risk factor, but it has been theorized to relate to both sexual aggression and HIV risk behavior. Thus, this study sought to (1) confirm the relationship between sexual aggression and HIV risk behavior, (2) establish CSA and negative affect as shared risk factors for sexual aggression and HIV risk behavior, and (3) evaluate whether negative affect mediates the relationship between CSA and sexual aggression and between CSA and HIV sexual risk in a sample of heterosexual men. We recruited 18- to 30-year-old heterosexual men (N = 377) from urban sexually transmitted infection clinics. Men completed measures of sexual HIV risk history (number of partners and condom use), sexual aggression history, CSA history, and trait negative affect (anger, anxiety, and depression). Structural equation modeling was used to examine hypothesized direct and indirect relationships. In the final SEM model, sexual aggression history and sexual HIV risk behavior were correlated. CSA was associated with both types of problematic sexual behavior. Anxiety significantly mediated the relationship between CSA and sexual aggression and between CSA and sexual HIV risk behavior (χ ²[1300] = 2121.79, p < .001; CFI = 0.905; RMSEA [90% CI] = .044 [.041-.047]). Sexual aggression appears to be part of a constellation of sexual risk behaviors; thus, it may be possible to develop prevention programs that target both sexual HIV risk and sexual aggression. CSA is a shared risk factor for sexual aggression and HIV risk behavior through the pathway of anxiety. Thus, anxiety might be one promising target for intervention.

Women's reproductive decision making and abortion experiences in Cape Town, South Africa: A qualitative study

Unintended pregnancy is a significant public health issue in South Africa. Despite free services including contraception, women face structural and institutional barriers to accessing care. This qualitative study comprised interviews with 16 women aged 18 to 40 years and receiving post-abortion services at a public clinic in Cape Town. Data analysis revealed three main themes: personal journeys in seeking abortion, contraceptive experiences, and contrasting feelings of empowerment (in reproductive decision making) and disempowerment (in the health care system). Women perceived themselves as solely responsible for their reproductive health, but found it difficult to obtain adequate information or services.

Prevalence of Trichomonas vaginalis infection and protozoan load in South African women: a cross-sectional study

OBJECTIVES

Trichomonas vaginalis is thought to be the most common non-viral sexually transmitted infection worldwide. We investigated the prevalence, risk factors and protozoan load of T. vaginalis infection in South African women.

METHODS

A cross-sectional study of 604 women was conducted at 25 primary healthcare facilities in rural South Africa (Mopani district). T. vaginalis DNA was detected in vaginal and rectal swabs. In univariate and multivariate analyses, the T. vaginalis infection was investigated in relation to demographic characteristics, medical history and behavioural factors. The T. vaginalis load was determined as the logarithm of DNA copies per microlitre sample solution.

RESULTS

Collected vaginal and rectal swabs were tested for T. vaginalis DNA. Prevalence of vaginal T. vaginalis was 20% (95% CI 17.0% to 23.4%) and rectal 1.2% (95% CI 0.6% to 2.4%). Most women (66%) with a vaginal infection were asymptomatic. Factors associated with T. vaginalis infection were a relationship status of single (OR 2.4; 95% CI 1.5 to 4.0; p<0.001) and HIV positive infection (OR 1.6; 95% CI 1.0 to 2.6; p=0.041). Women with vaginal T. vaginalis infection were more likely to have concurrent Chlamydia trachomatis rectal infection than those without vaginal infection (12%vs3%; p<0.001; OR 4.1). A higher median T. vaginalis load was observed among women with observed vaginal discharge compared with those without vaginal discharge (p=0.025).

CONCLUSIONS

Vaginal trichomoniasis is highly prevalent in rural South Africa, especially among single women and those with HIV infection, and often presents without symptoms.

Perspectives on intimate relationships among young people in rural South Africa: the logic of risk

This paper explores how young people in rural South Africa understand gender, dating, sexuality and risk-taking in adolescence. The empirical material drawn upon consists of 20 interviews with young men and women (aged 18-19) and reflects normative gender patterns characterised by compulsory heterosexuality and dating as obligatory, and representing key symbols of normality. However, different meanings of heterosexual relationships are articulated in the interviews, for example in the recurring concept of 'passing time', and these meanings show that a relationship can be something arbitrary: a way to reduce boredom and have casual sex. Such a rationale for engaging in a relationship reflects one of several other normative gender patterns, which relate to the trivialisation of dating and sexual risk-taking, and which entail making compromises and legitimising deviations from the 'ideal' life-script and the hope of a better future. However, risks do not exclusively represent something bad, dangerous or immoral, because they are also used as excuses to avoid sex, HIV acquisition and early pregnancy. In conclusion, various interrelated issues can both undermine and/or reinforce risk awareness and subsequent risk behaviour. Recognition of this tension is essential when framing policies to support young people to reduce sexual risk-taking behaviour.

Everyday (in)equality at home: complex constructions of gender in South African families

BACKGROUND

High rates of violence and HIV have been documented within the South African context. Constructions of masculinity and femininity that position men as dominant and highly sexually active and women as subordinate and acquiescent have been found to contribute towards gender inequality. This inequality is in turn related to negative health consequences, specifically violence against women, children, and other men, as well as sexual risk. Within this context it becomes important to explore how problematic constructions of gender are being (re)produced and how these constructions are being challenged. Families have been identified as key sites in which gender is both constructed and enacted on a daily basis and it is within this space that children are first exposed to notions of gender.

OBJECTIVE

This article draws from a study that was intended to expand on the limited understandings of the ways in which gender (in)equality is constructed and conveyed within the context of South African families on an everyday basis.

DESIGN

Children and parents in 18 families from a range of different material and cultural backgrounds were interviewed about the meanings and practices of gender within their homes. Data were analysed using a Foucauldian discourse analysis.

RESULTS

The data reveal how problematic constructions of masculinity and femininity are (re)produced but also challenged within a range of different families. Gender and gender (in)equality are therefore routinely accomplished in complex ways.

CONCLUSIONS

These findings have important implications for promoting gender equality and therefore for disrupting violence and sexual risk as gendered health issues.

Gender-Focused HIV and Pregnancy Prevention for School-Going Adolescents: The Mpondombili Pilot Intervention in KwaZulu-Natal, South Africa

This pilot study evaluated a 15 session classroom intervention for HIV and pregnancy prevention among grade 8-10 boys and girls (ages 14-17) in rural South Africa, guided by gender-empowerment theory and implemented by teachers, nurses, and youth peer educators. Pre- and post-intervention surveys included 933 male and female students in two intervention and two comparison schools.

MAIN OUTCOME

condom use at last sex; secondary outcomes: partner communication; gender beliefs and values; perceived peer behaviors; self-efficacy for safer sex. At five months post-intervention, change in condom use did not differ between intervention and comparison schools. Intervention school youth had greater increases in self-efficacy for unsafe sex refusal [OR=1.61; 95% CI=1.01, 2.57] and condom use [OR=1.76; 95% CI=1.07, 2.89], partner communication [OR=2.42; 95% CI=1.27, 4.23], and knowledge of HIV testing opportunities [OR=1.76; 95% CI=1.08, 2.87]. This gender-focused pilot intervention increased adolescents' self-efficacy and partner communication, and has potential to improve preventive behaviors.

Impact of Intimate Partner Forced Sex on HIV Risk Factors in Physically Abused African American and African Caribbean Women

We examined associations between intimate partner forced sex (IPFS) and HIV sexual risk behaviors among physically abused Black women. Women aged 18-55 in intimate relationships were interviewed in health clinics in Baltimore, MD and St. Thomas and St. Croix, US Virgin Islands (USVI). Of 426 physically abused women, 38% experienced IPFS; (Baltimore = 44 and USVI = 116). USVI women experiencing IPFS were more likely to have 3+ past-year sex partners (AOR 2.06, 95% CI 1.03-4.14), casual sex partners (AOR 2.71, 95% CI 1.42-5.17), and concurrent sex partners (AOR 1.94, 95% CI 1.01-3.73) compared to their counterparts. Baltimore women reporting IPFS were more likely to have exchanged sex (AOR 3.57, 95% CI 1.19-10.75). Women experiencing IPFS were more likely to report their abuser having other sexual partners in Baltimore (AOR 3.30, 95% CI 1.22-8.88) and USVI (AOR 2.03, 95% CI 1.20-3.44). Clinicians should consider the influence of IPFS on individual and partnership HIV sexual risk behaviors.

The Role of Sexual Health Professionals in Developing a Shared Concept of Risky Sexual Behavior as it Relates to HIV Transmission

"Risky sexual behavior" accounts for the majority of new HIV infections regardless of gender, age, geographic location, or ethnicity. The phrase, however, refers to a relatively nebulous concept that hampers development of effective sexual health communication strategies. The purpose of this paper was to propose development of a shared conceptual understanding of "risky sexual behavior." We reviewed multidisciplinary HIV/AIDS literature to identify definitions of risky sexual behavior. Both the linguistic components and the social mechanisms that contribute to the concept of risky sexual behaviors were noted. Risky sexual behavior was often defined in a subjective manner in the literature, even in the scientific research. We urge a paradigm shift to focus on explicit behaviors and the social context of those behaviors in determining HIV risk. We also propose a new definition that reduces individual biases and promotes a broader discussion of the degree of sexual risk across a diversity of behavioral contexts. Sexual health professionals can strengthen practice and research initiatives by operating from a concise working definition of risky sexual behavior that is broadly transferable and expands beyond a traditional focus on identity-based groups.

Cross-sectional study of genital, rectal, and pharyngeal Chlamydia and gonorrhea in women in rural South Africa

BACKGROUND

Epidemiological data of genital chlamydia and gonorrhea, required to inform design and implementation of control programs, are limited for rural Africa. There are no data on the prevalence of rectal or pharyngeal infections among African women.

METHODS

A cross-sectional study of 604 adult women visiting 25 primary health care facilities in rural South Africa was conducted. Vaginal, anorectal, and oropharyngeal swabs were tested for Chlamydia trachomatis and Neisseria gonorrhoeae.

RESULTS

Prevalence of genital chlamydia was 16% and that of gonorrhea was 10%; rectal chlamydial infection was diagnosed in 7.1% and gonococcal in 2.5% of women. One woman had pharyngeal chlamydia. Most women with genital chlamydia (61%) and gonorrhea (57%) were asymptomatic. Independent risk factors for genital chlamydia were younger age (adjusted odds ratio [aOR], 0.96 per year; 95% confidence interval [CI], 0.93-0.98), hormonal contraceptive use (aOR, 2.2; 95% CI, 1.3-3.7), pregnancy (aOR, 2.4; 95% CI, 1.3-4.4), and intravaginal cleansing (aOR, 1.7; 95% CI, 1.04-2.8). Intravaginal cleansing was associated with genital gonorrhea (aOR, 1.9; 95% CI, 1.1-3.3).

CONCLUSIONS

Genital and rectal, but not pharyngeal, chlamydia and gonorrhea are highly prevalent and frequently asymptomatic in women in rural South Africa. Young women attending health care facilities for antenatal care or family planning should be prioritized in control efforts.

Risky Sexual Behavior and Substance Use among Adolescents: A Meta-analysis

This study presents the results of a meta-analysis of the association between substance use and risky sexual behavior among adolescents. 87 studies fit the inclusion criteria, containing a total of 104 independent effect sizes that incorporated more than 120,000 participants. The overall effect size for the relationship between substance use and risky sexual behavior was in the small to moderate range (r = .22, CI = .18, .26). Further analyses indicated that the effect sizes did not substantially vary across the type of substance use, but did substantially vary across the type of risky sexual behavior being assessed. Specifically, mean effect sizes were smallest for studies examining unprotected sex (r = .15, CI = .10, .20), followed by studies examining number of sexual partners (r = .25, CI = .21, .30), those examining composite measures of risky sexual behavior (r = .38, CI = .27, .48), and those examining sex with an intravenous drug user (r = .53, CI = .45, .60). Furthermore, our results revealed that the relationship between drug use and risky sexual behavior is moderated by several variables, including sex, ethnicity, sexuality, age, sample type, and level of measurement. Implications and future directions are discussed.

The effects of gender and socioeconomic status on youth sexual-risknorms: evidence from a poor urban community in South Africa

HIV and AIDS remains one of the most serious problems facing youths in many sub-Saharan African countries. Among young people in South Africa, gender is linked with a number of HIV-risk behaviours and outcomes. The literature suggests that factors such as socioeconomic status, intimate partner violence, and several psychosocial factors contribute to gendered differences in sexual behaviour among youths in South Africa. However, the existing body of literature scarcely addresses the interaction between gender, confounding factors (particularly peer norms) and sexual behaviour outcomes. This study uses a survey design (n = 809) to examine how gender and socioeconomic status moderate the effects of norms and attitudes on higher-risk sexual behaviours among secondary school learners in a low-income community in South Africa. The findings suggest that gender interacts significantly with peer norms to predict sexual behaviour. Peer norms and the experience of intimate partner violence were significantly associated with sexual risk behaviour among girls participating in the study. The article discusses both the wider implications of these findings and the implications for school-based and peer-facilitated HIV interventions.

Gender, relationship dynamics and South African girls' vulnerability to sexual risk

South African researchers have stressed the importance of gender and relationship dynamics underlying sexual risk, particularly among 15- to 19-year-olds. Nevertheless, we know little about these factors among young girls, who are especially at risk of HIV. The main objective in this study was to explore the ways that young girls aged 16 to 17 years give meaning to boys and boyfriends and the processes through which these relationship dynamics are shaped. In-depth interviews were conducted with a group of black girls in a working class context in Durban about their sexual relationships with boys. Dominant gender norms underlined the ways in which girls discussed these sexual relationships in relation to their lack of power and condom use. Factors such as their class, race and gender interacted with girls' vulnerability to risk of HIV. While girls were complicit in their subordination, particularly in relation to cheating boyfriends, many were critical of boys who displayed patterns of sexual domination. Efforts aimed at reducing sexual risk must work toward shifting dominant patterns of masculinity over femininity to broaden pathways of love, trust, loyalty and understanding.

Assessing the implementation effectiveness and safety of 1% tenofovir gel provision through family planning services in KwaZulu-Natal, South Africa: study protocol for an open-label randomized controlled trial

BACKGROUND

The Centre for the AIDS Programme of Research in South Africa (CAPRISA) 004 trial demonstrated a 39% reduction in HIV infection, with a 54% HIV reduction in women who used tenofovir gel consistently. A confirmatory trial is expected to report results in early 2015. In the interim, we have a unique window of opportunity to prepare for and devise effective strategies for the future policy and programmatic scale-up of tenofovir gel provision. One approach is to integrate tenofovir gel provision into family planning (FP) services. The CAPRISA 008 implementation trial provides an opportunity to provide post-trial access to tenofovir gel while generating empiric evidence to assess whether integrating tenofovir gel provision into routine FP services can achieve similar levels of adherence as the CAPRISA 004 trial.

METHODS/DESIGN

This is a two-arm, open-label, randomized controlled non-inferiority trial. A maximum of 700 sexually active, HIV-uninfected women aged 18 years and older who previously participated in an antiretroviral prevention study will be enrolled from an urban and rural site in KwaZulu-Natal, South Africa. The anticipated study duration is 30 months, with active accrual requiring approximately 12 months (following which an open cohort will be maintained) and follow-up continuing for approximately 18 months. At each of the two sites, eligible participants will be randomly assigned to receive tenofovir gel through either FP services (intervention arm) or through the CAPRISA research clinics (control arm). As part of the study intervention, a quality improvement approach will be used to assist the FP services to expand their current services to include tenofovir gel provision.

DISCUSSION

This protocol aims to address an important implementation question on whether FP services are able to effectively incorporate tenofovir gel provision for this at-risk group of women in South Africa. Provision of tenofovir gel to the women from the CAPRISA 004 trial meets the ethical obligation for post-trial access, and helps identify a potential avenue for future scale-up of microbicides within the public health system of South Africa.

TRIAL REGISTRATION

This trial was registered with the South Africa Department of Health (reference: DOH-27-0812-4129) and ClinicalTrials.gov (reference: NCT01691768) on 05 July 2012.

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.

Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes

Background

Stigma is a determinant of social and health inequalities. In addition, some notions of masculinity can disadvantage men in terms of health outcomes. However, few studies have explored the extent to which these two axes of social inequality intersect to influence men’s health outcomes. This paper investigates the intersection of HIV stigma and masculinity, and its perceived impact on men’s participation in and utilisation of HIV services in Uganda.

Methods

Interviews and focus group discussions were conducted in Mbale and Jinja districts of Uganda between June and October 2010. Participants were men and women living with HIV (n = 40), their family members (n = 10) and health providers (n = 15). Inductive analysis was used to identify mechanisms through which stigma and masculinity were linked.

Results

Our findings showed that HIV stigma and masculinity did not exist as isolated variables, but as intersecting phenomena that influenced men’s participation in HIV services. Specifically, HIV stigma threatened masculine notions of respectability, independence and emotional control, while it amplified men’s risk-taking. As a result, the intersection of masculinity and HIV stigma prevented some men from i) seeking health care and accepting a ‘sick role’; ii) fulfilling their economic family responsibilities; iii) safeguarding their reputation and respectability; iv) disclosing their HIV status; and v) participating in peer support groups. Participation in some peer support activities was considered a female trait and it also exacerbated HIV stigma as it implicitly singled out those with HIV. In contrast, inclusion of income-generating activities in peer support groups encouraged men’s involvement as it enabled them to provide for their families, cushioned them from HIV stigma, and in the process, provided them with an opportunity to redeem their reputation and respectability.

Conclusion

To improve men’s involvement in HIV services, the intersection between HIV stigma and masculinity should be considered. In particular, better integration of and linkage between gender transformative interventions that support men to reconstruct their male identities and reject signifiers of masculinity that prevent their access to HIV services, and stigma-reduction interventions that target social and structural drivers of stigma is required within HIV programmes.

HIV transmission risk behavior among HIV-positive patients receiving antiretroviral therapy in KwaZulu-Natal, South Africa

The aim of this investigation was to identify factors associated with HIV transmission risk behavior among HIV-positive women and men receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa. Across 16 clinics, 1,890 HIV+ patients on ART completed a risk-focused audio computer-assisted self-interview upon enrolling in a prevention-with-positives intervention trial. Results demonstrated that 62 % of HIV-positive patients' recent unprotected sexual acts involved HIV-negative or HIV status unknown partners. For HIV-positive women, multivariable correlates of unprotected sex with HIV-negative or HIV status unknown partners were indicative of poor HIV prevention-related information and of sexual partnership-associated behavioral skills barriers. For HIV-positive men, multivariable correlates represented motivational barriers, characterized by negative condom attitudes and the experience of depressive symptomatology, as well as possible underlying information deficits. Findings suggest that interventions addressing gender-specific and culturally-relevant information, motivation, and behavioral skills barriers could help reduce HIV transmission risk behavior among HIV-positive South Africans.

Gendered discourses of youth sexualities--an exploration of PubMed articles on prevention of sexually transmissible infections

OBJECTIVE

To explore how gender is addressed in medical articles on the prevention of sexually transmissible infections (STI) among adolescents.

METHODS

Sixtyone articles were retrieved from a PubMed search and scrutinized by qualitative content analysis.

RESULTS

Most articles were affiliated with North American research institutions, but there were also reports from Europe, Africa, South America, and Asia. Gender turned up in the following four recurrent discourses: Gendered Receptiveness for Information, Stereotyped Heterosexual Expectations, Power Imbalance in Sexual Relations, and Gendered Prevention Approaches. Young women were described as knowledgeable, communicative, and responsible, but at risk because of feminine ideals and a lack of negotiating power. Men were described as less informed, more reluctant to discuss, and more risk taking due to masculine ideals and power dominance. Prevention approaches concerned how to postpone sex and/or tailor gender-sensitive programs for specific groups of young women and men.

CONCLUSION

Researchers' own gender expectations might have a substantial impact on how sex and sexual health is considered in prevention research. To avoid reconstruction of current inequalities and stereotypes regarding sexual practices of young women and men, the impact of gender, the power structures in intimate relations, and the cultural context should be considered. Medical research on STI prevention could benefit from including a wider array of gender perspectives.

Male victims of sexual violence in rural Malawi: the overlooked association with HIV infection

In sub-Saharan Africa, research on intimate partner violence (IPV) has largely failed to consider men's experiences as victims by female perpetrators - particularly within ongoing heterosexual relationships such as marriage. The objectives of this study were to document the prevalence of sexual coercion among men, to describe the characteristics of male victims, and to test for an association between sexual coercion and HIV positivity. In 2010, cross-sectional data on HIV risk behaviors, HIV status, and IPV were collected from a sample of 684 mostly married men in rural Malawi. Bivariate analyses were used to examine differences in HIV risk characteristics between victims and nonvictims of sexual coercion. Multivariate logistic regression was used to determine the association between sexual coercion and HIV positivity. Over one-tenth (10.4%) of men reported being a victim of sexual coercion. Male victims of sexual coercion were more likely to be married (p < 0.05), older than 24 years (p < 0.05), physically abused by a female partner (p < 0.001), believed their partners were at higher risk for HIV (p < 0.05), and had consumed alcohol in the past month (p < 0.01). After controlling for potential confounders, the odds of being HIV positive were 7.2 times higher among men who had experienced sexual coercion (p < 0.000). In sub-Saharan Africa, research on men's experience of violence as victims is long overdue. More formative research is needed to understand the mechanisms through which men experience violence and how to appropriately measure IPV among male victims. While the data are cross-sectional and cannot evaluate causality, the strength of the association with HIV positivity merits further attention.

Forced sexual initiation, sexual intimate partner violence and HIV risk in women: a global review of the literature

Coerced or forced sexual initiation and sexual intimate partner violence (sexual IPV) contribute significantly to a woman's risk for HIV infection. This review systematically examines global research (n = 21 studies) published since 2000 on the role of coerced/forced sexual initiation and sexual IPV on HIV risk in women. In predominantly low- and middle-income countries, coerced/forced sexual initiation was associated with HIV/STIs, multiple and high-risk sex partners, and no condom use. Most studies using behaviorally specific terms for sexual IPV found strong associations between sexual IPV and HIV risk behaviors. In contrast, studies using less specific definitions often failed to find these significant associations. To develop more comprehensive HIV prevention programs, future efforts should integrate behaviorally specific terms into assessing prevalence of sexual IPV and its association with HIV risk, consider cultural differences, and identify causal pathways between coerced or forced sexual initiation, HIV risk behaviors and HIV/STI infection.

Gender, peer and partner influences on adolescent HIV risk in rural South Africa

BACKGROUND AND METHODS

In preparation for a school-based intervention in KwaZulu-Natal, South Africa, a cross-sectional survey of potential HIV risk factors in youth aged 14-17 (n=983) was conducted.

RESULTS

Boys were significantly more likely than girls to report lifetime sexual activity (37.7% v. 13.8%, P<0.01). Among boys and girls, 46.1% reported condom use at last sex. Discussion of condom use with a partner was the strongest predictor of condom use (boys, odds ratio (OR)=7.39; girls, OR=5.58, P<0.0001). Age was independently associated with sexual activity for boys (OR=1.49, P<0.0001) and girls (OR=1.74, P=0.02). For boys, perceptions of male peer behaviour were associated with both ever having participated in sexual activity (OR=1.48, P<0.01) and condom use at last sex (OR=1.79, P<0.01). Girls who equated condom use with having numerous partners were more likely to use them. Among boys, results challenged some expected gender beliefs: support for girls' initiative in relationship formation and refusal of sex were significant predictors of sexual activity. Among girls, higher pregnancy risk perception (OR=1.32, P=0.02) and knowledge (OR=4.85, P=0.055) were associated with sexual activity.

CONCLUSIONS

Creating more gender equitable norms can reduce HIV risk behaviours. HIV prevention interventions should build on existing gender equitable beliefs, and work to promote others, including sexual communication and negotiation skills, and modelling of positive peer norms.

Overview of microbicides for the prevention of human immunodeficiency virus

Human immunodeficiency virus (HIV) prevention tools that women can use and control are urgently needed. Microbicides are chemical products applied to the vagina or rectum to prevent the sexual transmission of HIV. Four classes of candidate microbicides have been tested to date: those that (1) enhance the natural defences in the vagina to inactivate HIV; (2) inactivate HIV in the vagina; (3) prevent HIV from attaching to, and fusing with, the host cells; and (4) prevent HIV from replicating in genital tract host cells. Despite numerous disappointing efficacy trial results over the past 20 years, substantial progress is now being made in microbicide development after the release of the CAPRISA 004 trial, which provided proof-of-concept that topical antiretroviral microbicides can prevent sexual transmission of HIV and herpes simplex type-2 infection. Microbicides, which fill an important gap for women-controlled prevention methods, have the potential to alter the course of the HIV pandemic.

Everywhere you go, everyone is saying condom, condom. But are they being used consistently? Reflections of South African male students about male and female condom use

Young men in South Africa can play a critical role in preventing new human immunodeficiency virus (HIV) infections, yet are seldom targeted for HIV prevention. While reported condom use at last sex has increased considerably among young people, consistent condom use remains a challenge. In this study, 74 male higher education students gave their perspectives on male and female condoms in 10 focus group discussions. All believed that condoms should be used when wanting to prevent conception and protect against HIV, although many indicated that consistent condom use was seldom attained, if at all. Three possible situations for not using condoms were noted: (i) when sex happens in the heat of the moment and condoms are unavailable, (ii) when sexual partnerships have matured and (iii) when female partners implicitly accept unprotected sex. Men viewed it as their responsibility to have male condoms available, but attitudes about whose decision it was to initiate condom use were mixed. Almost all sexually active men had male condom experience; however, very few had used female condoms. Prevention initiatives should challenge traditional gendered norms that underpin poor condom uptake and continued use and build on the apparent shifts in these norms that are allowing women greater sexual agency.

Correlates of forced sex among populations of men who have sex with men in Thailand

Although forced sex is a correlate of HIV infection, its prevalence and associated risks are not well described among men who have sex with men (MSM) in developing-country settings. Between March and October 2005, we assessed the prevalence of forced sex and correlates among populations of MSM (this includes general MSM, male sex workers, and male-to-female transgender persons) in Thailand using a community-based sample. Participants were enrolled from venues around Bangkok, Chiangmai, and Phuket using venue day-time sampling. Handheld computer-assisted self-interviewing was used to collect demographic and behavioral data and logistic regression evaluated factors associated with forced sex, defined as ever being forced to have sexual intercourse against one's will. Of the 2,049 participants (M age, 24.8 years), a history of forced sex was reported by 376 (18.4%) men and, of these, most were forced by someone they knew (83.8%), forced more than once (67.3%), and had first occurrence during adolescence (55.1%). In multivariate analysis, having a history of forced sex was significantly associated with being recruited in Phuket, classification as general MSM or transgender (versus classification as male sex worker), drug use, increased number of male sexual partners, and buying sex. The findings in our assessment were consistent with assessments from Western countries. Longitudinal studies are needed to understand the mechanisms of the relationships between forced sex correlates found in our assessment and HIV acquisition and transmission risks.

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

Despite high levels of awareness of HIV, condom use, particularly consistent use, is suboptimal among young South African women. This paper aims to investigate the factors associated with both any condom use and consistent use by young rural women. In this study 1204 sexually active female volunteers, aged 15-26 years, were selected using a two-stage procedure in which firstly 70 clusters were selected and thereafter up to 20 women per cluster were selected, to participate in a cluster randomised controlled trial of an HIV behavioural intervention. This study is analysing cross-sectional data from a baseline survey thus no causal inferences can be drawn. A structured questionnaire was administered at a baseline interview. An estimated 19.9% of young women reported consistent condom use in the 12 months before the interview, while 44.5% reported inconsistent use. Any condom use was associated with higher condom use self-efficacy (adjusted odds ratio (aOR) 1.59; 95% CI 1.41, 1.77), less association of trust with suggested condom use (aOR 0.86; 95% CI 0.82, 0.91), knowing one's HIV status (aOR 2.86; 95% CI 1.52, 5.39) and having a more educated mother (aOR 1.71; 95% CI 1.26, 2.33). Having had just one partner was associated with a lesser likelihood of any condom use (aOR 0.14; 95% CI 0.10, 0.20). Consistent use, compared with inconsistent use, was associated with having just one partner (aOR 3.25; 95% CI 2.23, 4.73), less relationship conflict (aOR 0.84; 95% CI 0.75, 0.91) and higher gender equity in relationships with a male partner (aOR 1.43; 95% CI 1.15, 1.77). Our findings suggest that gender equity, monogamy and harmonious relationships play a positive role in enabling women to reduce their risk for HIV infection. Such aspects of relationship context could form a significant part of the progressive strategies required for HIV-prevention interventions to be successful.

Alcohol use before sex and HIV risk: situational characteristics of protected and unprotected encounters among high-risk African women

OBJECTIVES

To compare the situational characteristics of protected and unprotected sexual encounters that involved alcohol use 2 hours prior with ones that did not.

METHODS

Data were collected between December 2002 and December 2005 as part of enrollment in a prospective cohort study designed to identify HIV seroconversion risk factors among women bar and hotel workers in Northern Tanzania. A total of 608 (37.3%) of the women who were inconsistent condom users were asked a set-matched questions concerning situational characteristics surrounding their last protected and unprotected sexual encounter including whether they had been drinking within 2 hours of sex. The associations between drinking 2 hours before sex (yes/no), condom use (protected/unprotected), and their interaction with the situational descriptors were examined with a 2 x 2 model for paired categorical data after controlling for time since the last type of encounter.

RESULTS

Condom failure was 5 times more likely if someone (woman, man, or both partners) had been drinking in advance of the encounter (OR, 5.19; 95% CI, 2.05-15.46) and was especially likely to occur if only the woman had been drinking before sex (OR, 14.05; 95% CI, 4.03-50.41). Alcohol use before sex was associated with sexual contacts where the woman was having sex with her partner for the first time, their relationship was casual or transitory or sex was transactional, the location was unfamiliar and less under her control, and the partner had been drinking or using drugs before having sex. Condom use was more frequent in precisely the same types of encounters. Interestingly, there were no significant interactions between alcohol use before sex and condom use, suggesting that drinking before sex and use of condom are distinct and not contingent risk factors.

CONCLUSIONS

Alcohol use before sex is associated with an increased likelihood of condom failures and with high-risk sexual encounters, ones that have consistent situational characteristics regardless of whether condoms are used or not.

HIV risk behaviours and their relationship to intimate partner violence (IPV) among men who have multiple female sexual partners in Cape Town, South Africa

HIV/AIDS and intimate partner violence (IPV) are growing public health concerns in South Africa. Knowledge about adult men's perpetration of IPV and links between HIV risk behaviours and IPV is limited. Respondent driven sampling was used to recruit men who have multiple concurrent female sexual partners. Forty-one percent of the 428 recruited men had perpetrated IPV. Inconsistent condom use was associated with physical IPV; experiencing a symptom of a sexually transmitted infection and engaging in transactional sex were associated with physical and sexual IPV; problem alcohol use was associated with physical, and any IPV, but not sexual IPV; having five or more partners was associated with sexual IPV; perceptions of partners' infidelity were associated with physical and any IPV. HIV risk reduction interventions among men, especially those with multiple female sex partners, should incorporate strategies to change the underlying construction of masculinity that combines the anti-social and risky behaviours of IPV perpetration, inconsistent condom use, transactional sex and heavy alcohol consumption.

Spousal intimate partner violence is associated with HIV and Other STIs among married Rwandan women

HIV is a health problem in Rwanda, where the adult HIV prevalence is 3.1% (WHO 2008 in Online database of HIV/AIDS epidemiological data, found at: http://www.who.int/globalatlas ); the majority of those infected are women (UNAIDS 2008 in http://data.unaids.org/pub/Report/2008/rwanda_2008_country_progress_report_en.pdf ). Prior studies indicate that intimate partner violence is frequently associated with increased HIV risk in women, often because men who abuse their wives also exhibit riskier sexual behaviors (Silverman et al. in JAMA 300:703-710 2008. Population-based data from the 2005 Rwanda Demographic and Health Survey indicate that women with few, if any, other sexual risk factors who have experienced sexual, physical, or emotional abuse within their marriages are 1.61-3.46 times as likely to test positive for HIV, and 2.14-4.11 times more likely to report another STI. These findings confirm prior clinical studies that indicate that intimate partner violence is a correlate of HIV/STIs in Rwanda. Further research is needed to determine whether Rwandan men that abuse their wives have higher baseline rates of HIV/STI infection.

Changing trends and the impact of alcohol on the HIV/AIDS epidemic in South Africa: review

The association between increased HIV infection and alcohol use has been extensively studied and is established. South Africa is among one of the sub-Saharan African countries with the highest prevalence and number of people living with HIV/AIDS in the world. Although recent evidence suggests that the epidemic has stabilised, infection rates remain unacceptably high. Alcohol use is on the increase, particularly in the groups most susceptible to HIV infection, namely women and young adults, and informs poor choices with respect to safer sexual practices. This paper reviews the association between alcohol and HIV. More specifically, however, it aims to explore the potential socio-politico-biological and cultural explanations as to the factors that intersect to drive these two epidemic diseases: alcoholism and HIV/AIDS in South Africa. Understanding some of the underlying factors will provide a framework to implement public health measures to curb HIV.

The fallacy of intimacy: sexual risk behaviour and beliefs about trust and condom use among men who have sex with men in South Africa

The objective of this study is to assess (1) whether beliefs about trust and condom use affect sexual risk behaviour, and (2) if beliefs about trust and condom use impact sexual risk behaviour directly or if this relationship is mediated by other determinants. The Information-Motivation-Behavioural Skills model was used as a framework for the mediation analysis. A diverse cohort of three hundred 18-40 year old men who have sex with men (MSM) residing in Pretoria, South Africa, were recruited and surveyed for this project. Findings indicate that men who report a high frequency of past unprotected anal intercourse are more likely to believe that it is not necessary to use condoms with a trusted or steady partner regardless of their current partnership status. This fallacy of intimacy appears to affect sexual risk behaviour through intentions and attitudes regarding safer sex practices. Based on these findings, we recommend that more attention be given in gaining a better understanding of how beliefs about trust and condom use are formed and how they can be changed among MSM in South Africa.

In the absence of marriage: long-term concurrent partnerships, pregnancy, and HIV risk dynamics among South African young adults

In KwaZulu/Natal, South Africa, where HIV prevalence is among the world's highest, a longitudinal qualitative study of partnership dynamics and HIV preventive behaviors was conducted. 47 young adults aged 18-24 participated in in-depth interviews, and 29 were re-interviewed 2 years later. Five analytical domains emerged: primary partnerships, love and romance; secondary partnerships; pregnancy/parenthood; condom use/prevention; and contextual influences, including schooling and future aspirations. Primary relationships were long-lasting, with most men and women in the same relationship at 2-year follow-up. Secondary, casual partnerships were common for men and women, although these were shorter and changed frequently. Love and marriage aspirations were not viewed as incompatible with secondary partners. Condom use increased over time in some primary relationships, but decreased in others, and was nearly universal with non-primary partners. Pregnancy, school drop-out, and economic need strongly influence young people's lifecourse. These findings suggest the need to focus prevention efforts on the partnership context, including partner reduction, and structural factors that impede or enhance prevention success.

Condom negotiation: experiences of sexually active young women

AIM

This paper is a report of a study of sexually active young women's experiences of negotiating condom use both before and after diagnosis of a sexually transmitted infection.

BACKGROUND

The male condom is the most efficient method in preventing and reducing the transmission of sexually transmitted infections. However, condom use can be hindered by factors including societal norms and gender roles, which can create difficulties for women in initiating and negotiating condom use in heterosexual partnerships.

METHODOLOGY

A feminist narrative approach was used, and ten women's stories were collected via online interviews in 2007.

FINDINGS

None of the women initiated or negotiated use of the male condom for various reasons. Some relied on their male partners to initiate condom use, some were unable to practise safer sex due to the abuse and unequal gender dynamics that existed in their sexual relationships, and some thought that condom use was not necessary because of a belief that they were in safe and monogamous relationships. Even following diagnosis of a sexually transmitted infection, some women said that they were not empowered enough to initiate condom use with subsequent sexual partners, resulting in continued high-risk sexual behaviour.

CONCLUSION

Successful condom promotion relies on the recognition of the gender factors that impede young women's condom negotiation and use. Strategies that overcome gender dynamics and empower women to negotiate condom use have the ability to promote condom use among this group.

Preventing HIV infection in women: a global health imperative

Women account for approximately one-half of all human immunodeficiency virus (HIV) infections worldwide. Sexual transmission is the dominant mode of HIV transmission to women, and there is a concomitant associated epidemic of transmission to infants. The majority of HIV infections in women are in sub-Saharan Africa, with a disproportionate burden in young women <25 years of age. Acquisition and prevention of HIV infection in women is complex and influenced by biological, behavioral, and structural factors. Efforts to reduce the incidence of HIV infection among women in sub-Saharan African could play a substantial role in altering global trajectories of HIV infection. Increasing access to sexual and reproductive health services, addressing gender-based violence and social instability, reducing poverty and the need to engage in sex for survival, and encouraging greater male responsibility are critical short-to-medium-term interventions. Efforts to find a microbicide and HIV vaccine need to be matched with efforts to deepen understanding of acquisition of HIV in the female genital tract to inform development of targeted molecules for prevention of HIV infection.

Integrating HIV prevention into services for abused women in South Africa

The relationship between intimate partner violence (IPV) and HIV risk is well documented, but few interventions jointly address these problems. We developed and examined the feasibility of an intervention to reduce HIV risk behaviors among 97 women seeking services for IPV from a community-based NGO in Johannesburg, South Africa. Two versions of the intervention (a 6-session group and a 1-day workshop) were implemented, both focusing on HIV prevention strategies integrated with issues of gender and power imbalance. Attendance was excellent in both intervention groups. Assessments were conducted at baseline, post-intervention and two-month follow-up to demonstrate the feasibility of an intervention trial. Women in both groups reported reductions in HIV misperceptions and trauma symptoms, and increases in HIV knowledge, risk reduction intentions, and condom use self-efficacy. The 6-session group showed greater improvements in HIV knowledge and decreases in HIV misperceptions in comparison to the 1-day workshop. The study demonstrated the feasibility and potential benefit of providing HIV prevention intervention to women seeking assistance for IPV.

Understanding Women's Risk for HIV Infection Using Social Dominance Theory and the Four Bases of Gendered Power

Theoretical models to date have fallen short of accounting for the alarming worldwide rates of HIV infection in women through heterosexual contact. In this article, social dominance theory and the four bases of gendered power—force, resource control, social obligations, and consensual ideologies—are used to organize and explain international research findings on women's risk of contracting HIV from male sexual partners. Research suggests that the four bases of gendered power contribute to women having less power than men in heterosexual relationships, resulting in challenges to preventing HIV transmission from male partners. Social dominance theory also recognizes the intersections among various group-based hierarchies, such as race and class, thereby helping explain why women of color and low-income women are disproportionately affected by HIV. The intergroup focus of social dominance theory points to gender inequality as increasing men's risk of HIV infection as well, and the construct of social dominance orientation helps to explain individual differences in HIV risk behavior. We discuss the ways the current theoretical framework can prove useful in helping to guide future research addressing the connections between power and HIV risk, including exploring mediators and links to other theoretical models. We also discuss the implications the framework has for intervention efforts aimed at reducing HIV rates worldwide, such as supporting efforts at increasing women's representation in hierarchy-enhancing positions, incorporating empowerment issues into current interventions, promoting use of female condoms, and targeting heterosexual men for interventions.

The association between sexual aggression and HIV risk behavior in heterosexual men

Perpetrating sexual coercion and rape can be conceptualized as a form of sexual risk taking. In this study, the authors evaluated the relationship between sexual aggression and other risky sexual behaviors (e.g., intercourse without a condom) using an online convenience sample of 1,240 heterosexual men. Sexually aggressive men engaged in more sexual risk taking (i.e., sex with multiple partners, unprotected sex, and one-night stands) than nonaggressive men, and almost half of the reported incidents of sexual aggression were unprotected (i.e., no condom was worn). Thus, sexual aggression was found to be part of a larger pattern of sexual risk taking. Regression analyses revealed that sexual aggression was associated with greater alcohol use and lower sexual inhibition-two variables that have consistently been found to be related to other forms of sexual risk taking.

Gender norms in South Africa: implications for HIV and pregnancy prevention among African and Indian women students at a South African tertiary institution

In post-Apartheid South Africa, women are constitutionally guaranteed protections and freedoms that were previously unknown to them. These freedoms may have positive implications for women's ability to negotiate sexual protection with partners and hence prevent unintended pregnancy and decrease their risk of HIV. Among tertiary institution students, who are a relatively 'privileged' group, there is little information on gender norms that might shape responses to HIV-prevention programmes. To elicit gender norms regarding women's and men's roles, condom and contraceptive use, sexual communication and sexual pleasure, we conducted 10 semi-structured focus group discussions with African and Indian female tertiary institution students in order to understand how norms might be used to buttress HIV- and pregnancy-prevention. Participants reported dramatic changes in the structure of gender norms and relations with the formal recognition of women's rights in the post-Apartheid context. These generational shifts in norms are supported by other research in South Africa. At the same time, women recognized the co-existence of traditional constructions of gender that operate to constrain women's freedom. The perceived changes that have taken place provide an entry point for intervention, particularly for reinforcing emerging gender norms that promote women's protection against unintended pregnancy and HIV/STIs.

Gender-based violence and HIV: relevance for HIV prevention in hyperendemic countries of southern Africa

Gender-based violence (GBV) is common in southern Africa. Here we use GBV to include sexual and non-sexual physical violence, emotional abuse, and forms of child sexual abuse. A sizeable literature now links GBV and HIV infection.Sexual violence can lead to HIV infection directly, as trauma increases the risk of transmission. More importantly, GBV increases HIV risk indirectly. Victims of childhood sexual abuse are more likely to be HIV positive, and to have high risk behaviours.GBV perpetrators are at risk of HIV infection, as their victims have often been victimised before and have a high risk of infection. Including perpetrators and victims, perhaps one third of the southern African population is involved in the GBV-HIV dynamic.A randomised controlled trial of income enhancement and gender training reduced GBV and HIV risk behaviours, and a trial of a learning programme reported a non-significant reduction in HIV incidence and reduction of male risk behaviours (primary prevention). Interventions among survivors of GBV can reduce their HIV risk (secondary prevention). Various strategies can reduce spread of HIV from infected GBV survivors (tertiary prevention). Dealing with GBV could have an important effect on the HIV epidemic.A policy shift is necessary. HIV prevention policy should recognise the direct and indirect implications of GBV for HIV prevention, the importance of perpetrator dynamics, and that reduction of GBV should be part of HIV prevention programmes. Effective interventions are likely to include a structural component, and a GBV awareness component.