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

"For a man to go to hospital, then that would be his last option": A qualitative study exploring men's experiences, perceptions and healthcare needs in the implementation of Universal Health Coverage in Kenya

The achievement of Universal Health Coverage (UHC) requires equitable access and utilization of healthcare services across all population groups, including men. However, men often face unique barriers that impede their engagement with health systems which are influenced by a myriad of socio-cultural, economic, and systemic factors. Therefore, understanding men's perspectives and experiences is crucial to identifying barriers and facilitators to their healthcare-seeking behaviour under UHC initiatives. This qualitative study sought to explore men's perceptions, experiences, healthcare needs and potential strategies to inform an impartial implementation of Universal Health Coverage (UHC) in Kenya. The study employed a qualitative research design to investigate men's healthcare experiences in 12 counties across Kenya. Thirty focus group discussions involving 296 male participants were conducted. Men were purposively selected and mobilized through the support of health facility-in-charges, public health officers, and community health extension workers. Data was coded according to emergent views and further categorized thematically into three main domains (1) Perspectives and experiences of healthcare access (2) Socio-cultural beliefs and societal expectations (3) Desires and expectations of health systems. Findings revealed complex sociocultural, economic, and health system factors that influenced men's healthcare experiences and needs which included: masculinity norms and gender roles, financial constraints and perceived unaffordability of services, lack of male-friendly and gender-responsive healthcare services, confidentiality concerns, and limited health literacy and awareness about available UHC services. Our study has revealed a disconnect between men's needs and the current healthcare system. The expectations concerning masculinity further exacerbate the problem and exclude men further hindering men's ability to receive appropriate care. This data provides important considerations for the development of comprehensive and gender-transformative approaches challenging harmful masculine norms, pushing for financial risk protection mechanisms and gender-responsive healthcare delivery attuned to the unique needs and preferences of men.

"Even when you write with a pencil there is an eraser to clean it": Examining men's conceptualisations of and involvement in emergency contraceptive use in Accra, Ghana

Emergency contraceptive pills are an essential and unique post-coital method to avoid a pregnancy, with evidence showing the significant role men can have in procurement and decisions to use. Global Health recommendations specify that emergency contraceptive pills be used sparingly and under specific conditions. This increasingly misaligns with the myriad conceptualisations and rationales among the public for why they choose to use emergency contraceptive pills. There has been a paucity of research aiming to understanding men's involvement and how they shape women's access, choice, and autonomy. This study interrogates how emergency contraceptive pills are conceptualised by men in James Town, Ghana, and how this intersects with their motivations to be involved in its use. Mixed method data from a survey (n = 270) and in-depth interviews (n = 37) were collected between July 2020 and January 2021. The analysis examines men's framings of emergency contraceptive pills and how these shape their involvement in its use. Men's knowledge of post-coital contraceptives was high, while knowledge of the specific term 'emergency contraception' was lower. While some men understood the pills in ways that aligned to Global Health framings, many more men saw emergency contraceptive pills as another means of pregnancy prevention in line with other contraceptives. This included its conceptualisation as a contraceptive that facilitates pleasurable (condomless) and spontaneous sex. Gendered perceptions of women who use emergency contraceptive pills were bound in sexual stigma, and men indicated that emergency contraceptive pills were a directly observable form of contraception that they could pressure their partner into using. Understanding plural conceptualisations away from 'emergency' are necessary to create policies and programmes that account for men's involvement. This includes understanding how emergency contraceptive pills are located within people's sexual and reproductive lives and gendered power dynamics, to reflect the public's own rationales for and experiences using post-coital contraceptives.

Do adolescent girls' education and friendships have independent effects on early pregnancy? Results of a mediation analysis from a longitudinal cohort study in Nairobi, Kenya

Background

Few studies have examined whether the effect of education on pregnancy and childbearing is due to the academic skills acquired or the social environment that schooling provides. This paper explores whether adolescent girls' learning skills, school enrollment, grade attainment, and friendships affect risk of pregnancy, and whether friendships mediate the relationship between education and pregnancy.

Methods

We draw on three waves of longitudinal data on adolescent girls aged 11-15 in Kibera, an informal settlement in Nairobi, Kenya between years 2015-2019. We use fixed effects regression models to estimate effects of girls' learning skills, school attendance, grade attainment, and friendships on their probability of experiencing a pregnancy. We conduct mediation analyses to assess whether friendships mediate the relationship between education and pregnancy.

Results

By round one (2015), 0.1 % of girls reported having experienced a pregnancy; by round three (2019), 6.3 %. Even after adjusting for friendships, we find that attending school decreases probability of pregnancy by nine percentage points; an additional year of schooling decreases probability of pregnancy by three percentage points; and a one standard deviation increase in numeracy decreases probability of pregnancy by one percentage point. Having any male friends who do not attend school increases girls' probability of experiencing a pregnancy by four percentage points; this association remains after adjusting for girls' education. However, out-of-school girls are far more likely to report out-of-school male friends. We find no evidence that other types of friendships affect girls' probability of becoming pregnant.

Conclusion

We find significant protective effects of school attendance, higher grade attainment and numeracy skills on girls' pregnancy, and that having close friendships with out-of-school males increases girls' probability of pregnancy. We did not find evidence of meaningful mediation, suggesting that the protective effects of school attendance and learning remain regardless of any risk they may face from their friendships.

Is there an association between gender stereotypes and sexual risk attitudes and behaviors? A population-based study among Peruvian adolescents

BACKGROUND

Adolescents, particularly those aged 14 to 15 y, often begin exploring their sexuality, during which time they are more vulnerable to traditional influences and ideologies imposed by society. This study aimed to identify the association between more traditional attitudes toward women and sexual risk attitudes and behaviors in Peruvian adolescents.

MATERIALS AND METHODS

Cross-sectional study with data from the fifth round of the Young Lives study with 1860 adolescents aged 14 and 15 y. Population characteristics were described by relative frequencies and using chi-squared test with p-value. The 12 items of the Attitudes toward Women Scale for Adolescents instrument were analyzed by relative frequencies and mean with standard deviation. For further analysis, the values of the global scores of all participants were divided into two categories, using the median as the cutoff point, where the group with higher scores indicated that these adolescents had more traditional attitudes (or more gender stereotypes). More traditional attitudes were associated with sexual risk attitudes and behaviors, with crude prevalence ratio (PR) and then adjusted prevalence ratio (aPR) with 95% CI. The Universidad Privada de Tacna's ethics committee approved the research protocol.

RESULTS

Adolescents with more traditional attitudes were more likely to have sexual risk attitudes compared to those with less traditional attitudes. In addition, adolescents with more traditional attitudes were 2.6 times more likely to have at least one sexual intercourse while drunk as compared to the reference group (95% CI: 1.43-4.74; p=0.002).

CONCLUSIONS

The expression of more traditional attitudes toward women was associated with sexual risk attitudes. However, there was no association with most of the sexual risk behaviors studied, except for the higher probability of having at least one sexual intercourse while drunk.

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.

Sexual risk behaviour among school-going adolescents in Sierra Leone and Liberia: a secondary analysis of the 2017 Global school-based student health surveys

BACKGROUND

Sierra Leone and Liberia have experienced civil wars and, recently, Ebola outbreaks that led to profound economic hardship, psychopathologies and family disruptions. These factors are associated with sexual risk behaviours among youths. However, there is very little information on sexual risk behaviour among Sierra Leonean and Liberian school-going adolescents. The present study assessed the prevalence and determinants of sexual risk behaviours among school-going adolescents (10-19 years) in Sierra Leone and Liberia.  METHOD: We used publicly available nationally representative cross-sectional datasets of the 2017 Sierra Leone and Liberia Global school health survey. The sample consisted of 2798 and 2744 school-going adolescents from Sierra Leone and Liberia, respectively. Complex sample descriptive and regression analysis was used to analyse our data.

RESULTS

The majority of adolescents in the two countries were involved in multiple sexual risk behaviour (80.2%), with a higher prevalence observed in Sierra Leone (85.2%) than in Liberia (75.3%). Liberian adolescents showed lesser odds of indulging in multiple sexual risk behaviours than their Sierra Leonean counterparts (AOR = 0.572; 95%CI: 0.345-0.946). Male, compared to females, were more likely to engage in multiple sexual risk behaviour (AOR = 2.310;95%CI:1.543-3.458), with a similar pattern observed in both countries. Alcohol use was associated with multiple sexual risk behaviour (AOR = 3.064; 95%CI: 2.137-4.392). Also, in Sierra Leone and Liberia, adolescents with one and two or more forms of psychological distress were more likely to have ever had sex than those who did not show any form of psychological distress. Missing class/school was associated with multiple sexual risk behaviour (AOR = 1.655; 95%CI:1.133-2.418). Peer support was only found to be a protective factor against no condom use among Liberian adolescents (AOR = 0.608; 95%CI: 0.435-0.850). Less parental support was only associated with ever had sex among adolescents in Sierra Leone (AOR = 2.027; 95%CI: 1.322-3.107) but not in Liberia (AOR = 1.034; 95%CI: 0.650-1.644).

CONCLUSION

Our study found a high sexual risk behaviour among school-going adolescents in Sierra Leone and Liberia. Our finding highlights the need to strengthen sexual and reproductive health education in schools and communities that incorporate mental health promotion activities tailored to this group.

Intimate partner violence perpetration and sexual risk behaviour: Identifying shared determinants among young men in Tanzania

In this study we examined factors that predict involvement in different patterns of sexual risk behavior and IPV perpetration among young men in Tanzania (n = 979), with a focus on identifying factors that distinguish men who engage in both behaviours from those who do not. Risk factors were drawn from three domains thought to be upstream drivers of both IPV and sexual risk: poverty, adverse childhood experiences, and inequitable gender norms. A three-step latent class analysis was used to assess whether and how factors from each domain distinguished subgroups of men whose behaviour patterns were characterised as comorbid (involvement in IPV and sexual risk behaviour), IPV-only, sexual risk only, and normative (low risk). Consistent with expectations, greater food insecurity, adverse childhood experiences, and inequitable gender norms related to violence and sexual behaviour predicted increased risk of membership in the comorbid group compared to other sub-groups. Findings support the promise of integrated prevention programmes targeting the common causes of IPV perpetration and sexual risk behaviour.

Determinants of age at first sex inequality between women and men youth in Uganda: A decomposition analysis

INTRODUCTION

Teenage pregnancies and sexually transmitted diseases are major public health problems in Uganda. Early sexual debut is one of the main routes of these public health problems. This study aimed to identify factors that explain age at first sex inequality between men and women Ugandan youth.

METHODS

This study used secondary data from a cross-sectional Uganda demographic health survey (2016). Participants were 10 189 sexually experienced youth. Using Stata 14, intermediary analysis was done to assess the statistical association between explanatory variables and age at first sex in a multiple logistic regression analysis. Oaxaca decomposition was used to decompose factors that explain inequalities in age at first sex between men and women youth.

RESULTS

Intermediary results showed Islam, many household members, residing in the eastern region, and being divorced/widowed were predictors of early age at first sex. While secondary education, higher education, blue-collar jobs, and being 20 to 30 years old were protective factors against early age at first sex. Material, behavior/cultural, psychosocial, and demographic explanatory factors jointly explained a statistically significant portion of the observed gap in early age at first sex between women and men youth. More women were at a disadvantage at an early age at first sex compared to men youth. About 96.37% of this gap was explained by unequal distribution of material, behavior/cultural, psychosocial, and demographic factors between men and women youth. Relationship to household head (49%), education (16.87%), occupation (8,94%), number of household members (8.57%), using the internet (7.99%), and reading newspapers or magazines (4.39%) made a significant contribution to the explanation of early age at first sex inequality between men and women youth.

CONCLUSIONS

Results showed early age at first sex inequality between women and men youth that favored men. Programs designed to address early age at first sex and related health outcomes must combat inequities in education, employment opportunities, access to sexual reproductive information through internet, and newspapers or magazines between men and women youth. They should also foster household relationships and monitor girls.

Spousal Violence and Contraceptive Use among Married Afghan Women in a Nationally Representative Sample

OBJECTIVE

Afghanistan is one of the countries with the highest prevalence of spousal violence (56%) and a low prevalence of contraceptive use (23%), yet there is no study assessing how spousal violence is related to contraceptive use, and what methods are most used by women. Therefore, this study examined the association between the number of types of spousal violence and contraceptive use.

METHOD

Using data from 18,985 Afghan married women, aged 15 to 49, who responded to the 2015 Afghanistan Demographic and Health Survey, the current contraceptive method was grouped into five categories: male-involved methods, pills, injectables, long-acting reversible contraception, female sterilization, and Lactation Amenorrhea Method. The number of types of spousal violence in the past 12 months was categorized as none, one type, or two or more types, based on women's experiences with verbal, physical, and sexual violence. For analysis, binary and multinomial logistic regression were used.

RESULTS

After adjusting for the covariates, the experience of any spousal violence was associated with contraception use (adjusted odds ratio (aOR) = 1.93, 95% CI: 1.64-2.27, p = 0.0001). Among those using contraception, experiencing two or three types of spousal violence was associated with using pills (adjusted risk ratio (aRRR) = 2.12, 95% CI: 1.63-2.77, p = 0.0001), injections (aRRR = 1.75, 95% CI: 1.26-2.41, p = 0.001), and LAM (aRRR = 3.27, 95% CI: 2.05-5.20, p = 0.0001), compared to male-involved methods.

CONCLUSIONS

The findings of this study may inform policymakers and program implementers in designing interventions to address the pervasive problem of violence against women, and make pills and injectables more accessible to Afghan women, since these methods are under women's control and more often used in Afghanistan.

"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.

Differences in Sexual Behavior and Partner Notification for Sexually Transmitted Infections Between the Out of School Youth and University Students in a Peri-Urban District in South Africa-A Cross-Sectional Survey

The increase in sexually transmitted infections (STIs) in young people is a public health concern. Among those in university and out of school, different contextual factors contribute to their risky sexual behavior and increased susceptibility to STIs and HIV. There are limited comparative studies examining risky sexual behavior and partner notification (PN) between these two groups, particularly in South Africa. We investigated sexual behaviors, self-reported STI diagnosis, health seeking behavior, and preferred PN methods of university students and out of school youth. A descriptive cross-sectional survey was used using convenient sampling to select 917 students across five health sciences universities and through periodic sampling 699 out of school youth were selected from two main local shopping centers in South Africa. Descriptive statistics, bivariate and multivariable logistic analysis were performed using Stata IC version 14. More university students (71.7%) than out of school youth were in casual relationships (28.3%), with half of out of school youth being in steady relations (50.2%). Moreover, university students (65.7%) used a condom in the past 6 months compared to their counterparts (34.3%). Of the 124 youth who were diagnosed with STI in the past 12 months, majority (n = 106, 85%) were out of school youth. The probability of notifying a partner about a STI infection was 82% among university students compared to their counterparts (p = >0.05). The odds of notifying a partner was 1.79 times more for those having multiple sexual partners than those who had only one partner. Both groups preferred a face-to-face STI disclosure with partner; however, more university students (67%) preferred SMS notification than PN referral slips as compared to out of school youth (42%). Both the university students and the out of school youth engaged in risky sexual behaviors. Both groups preferred face-to-face and clinic SMS partner notifications, even though university students were in the majority. There is a need for developing health promotion scripts on disclosing STIs to sexual partners to empower the majority of the youth who prefer face-to-face PN over the prescribed methods.

Is There Risk Compensation among HIV Infected Youth and Adults 15 Years and Older on Antiretroviral Treatment in South Africa? Findings from the 2017 National HIV Prevalence, Incidence, Behaviour and Communication Survey

In this paper, risk compensation among individuals on antiretroviral therapy (ART), using the 2017 South African national survey on HIV, is explored. A multi-stage stratified cluster random sampling approach was used to realize 11,130 participants 15 years and older. Logistic regression analysis assessed the association between multiple sexual partners, condom use at last sexual encounter, consistency of condom usage and potential explanatory variables using HIV status and ART exposure as a mediator variable. HIV positive participants who were aware and on ART were less likely to have multiple sexual partners, and less likely not to use a condom at last sex compared to HIV positive participants who were aware but not on ART. The odds of reporting multiple sexual partners were significantly lower among older age groups, females, non-Black Africans, and rural settings, and higher among those with tertiary level education, and risky alcohol users. The odds of no condom use at last sexual encounter were more likely among older age groups, females, other race groups, and less likely among those with secondary level education. The odds of inconsistent condom use were more likely among older age groups, females, and other race groups, and less likely among those with tertiary level education, high risk and hazardous alcohol users. Risk compensation is not apparent among HIV infected adults who are on ART. Risk groups that should receive tailored interventions to reduced risky sexual behaviours were identified.

Exploring the Protective Value of Using Sexting for Condom Negotiation on Condom use Determinants and Practices Among Forcibly Displaced Adolescents in the Slums of Kampala, Uganda

Given the global growth of adolescent texting, we evaluate texting-based sexual communication as a potential site for interventions encouraging condom use cascades, particularly among displaced adolescents-a population with disproportionate levels of sexually transmitted infections, including HIV. With data from 242 forcibly displaced adolescents in the slums of Kampala, Uganda, we used path analysis to examine pathways from gender/dating relationship to condom determinant (knowledge of where to access condoms) and practices (access/use of condoms), through sexting-based condom negotiation, controlling for sexting practices. We found direct pathways from gender (boys vs. girls) and from dating relationship (dating vs. not) to condom determinant. Sexting-based condom negotiation partially mediated the pathway from gender/dating relationship to condom determinant, and fully mediated the pathways from gender/dating relationship to condom practices. Future digital sexual health interventions should consider the utility of texting-based applications in promoting knowledge and use of condoms among adolescents.

The Intersection of Intimate Partner Violence Perpetration and Sexual Risk Behavior Among Young Men in Tanzania: A Latent Class Analysis of Patterns and Outcomes

Few studies of intimate partner violence (IPV) perpetration and sexual risk behavior among men have examined how multiple dimensions of these behaviors intersect in ways that may uniquely elevate health risks. The current study used latent class analysis to: (1) identify distinct patterns of IPV and sexual risk behavior in a sample of Tanzanian men (n = 985) and (2) examine associations between identified patterns and health outcomes. Four classes were identified: normative (64% of the sample), IPV only (14%), sexual risk only (13%), and comorbid IPV/sexual risk (5%). Compared to men in the normative subgroup, men in the comorbid group had significantly higher odds of STI infection, higher perceived HIV risk, and greater odds of substance use. Findings provide evidence that engaging in IPV and multiple sexual partnerships (i.e., a comorbid pattern) denotes elevated health risks across a range of indicators, suggesting the importance of targeted treatment and prevention efforts for men in this subgroup.

A Structural Equation Model of the Effect of Masculinity and Avoidant Coping on Gay and Bisexual Men's Sexual Risk-Taking

This study aims to extend the scientific knowledge base on the association between masculine norm adherence and sexual risk-taking, in the context of gay and bisexual men, by examining emotional suppression, social support seeking, and avoidant coping as potential mediating pathways. A sample of 482 gay and bisexual men was recruited. Structural equation modeling was used to assess for mediation. Findings revealed that although gender role conflict and conformity to masculine norms (i.e., the two masculine norm adherence predictor variables) did not have a direct effect on sexual risk-taking, a significant indirect effect was observed for gender role conflict on sexual risk-taking via increased avoidant coping. Accordingly, gender role conflict and avoidant coping may create a unique effect on sexual risk-taking whereby the effect of gender role conflict on sexual risk-taking is not transmitted directly but only indirectly through the mediating role of avoidant coping. Future research directions are discussed.

Changing men or changing health systems? A scoping review of interventions, services and programmes targeting men's health in sub-Saharan Africa

BACKGROUND

Sex and gender have been shown to influence health literacy, health seeking behaviour, and health outcomes. However, research examining the links between gender and health has mainly focused on women's health, which is a long-standing global health priority. We examine literature focused on the 'missing men' in global health research, in particular empirical studies that document interventions, programmes, and services targeting men's health issues in Sub-Saharan Africa. Within these studies, we identify dominant conceptualisations of men and men's health and how these have influenced the design of men's health interventions and services.

METHODS

This is a scoping review of published and grey literature. Following comprehensive searches, we included 56 studies in the review. We conducted a bibliographic analysis of all studies and used inductive methods to analyse textual excerpts referring to conceptualizations of men and service design. An existing framework to categorise services, interventions, or programs according to their gender-responsiveness was adapted and used for the latter analysis.

RESULTS

From the included studies, we distinguished four principal ways in which men were conceptualized in programs and interventions: men are variously depicted as 'gatekeepers'; 'masculine' men, 'marginal' men and as 'clients. Additionally, we classified the gender-responsiveness of interventions, services or programmes described in the studies within the following categories: gender-neutral, -partnering, -sensitive and -transformative. Interventions described are predominantly gender-neutral or gender-partnering, with limited data available on transformative interventions. Health systems design features - focused mainly on achieving women's access to, and uptake of services - may contribute to the latter gap leading to poor access and engagement of men with health services.

CONCLUSION

This review highlights the need for transformation in sub-Saharan African health systems towards greater consideration of men's health issues and health-seeking patterns.

"I'd Rather Use a Refuse Bag:" A Qualitative Exploration of a South African Community's Perceptions of Government-Provided Condoms and Participant-Preferred Solutions

Despite South Africa experiencing one of the largest HIV epidemics in the world, condom use has decreased since 2008. However, condoms are the only low-cost HIV prevention technology widely available in South Africa. This study aims to explore a South African community's perceptions of condoms, recent condom use decrease, and suggestions for increasing condom use. In 2014, we conducted seven focus groups (n = 40 men) and 20 in-depth interviews (n = 9 men, n = 11 women) with participants aged ≥ 18 years recruited from four urban settlement health clinics in Cape Town, South Africa. Data were collected, coded, and analysed using a general inductive approach. Participants perceived government-provided condoms negatively, with themes including "disgust" for condom physical properties, concerns with social status associated with free condoms, and performance concerns. There was an intersection of themes surrounding masculinity, condom use, and sexual pleasure. Solutions to increase condom use included improving the quality and variety of free condoms and rebranding free condoms. Participants suggested that condoms are distributed with novel attributes (e.g., more colors, smells/flavors, sizes, and in-demand brands) and that government programs should consider offering all brands of condoms at no or low cost. This study suggests a substantial rethinking of condom branding for government-provided condoms. Our findings suggest that condom dissemination and promotion programs should proactively address public concerns regarding condoms. Existing societal and structural norms such as hegemonic masculinity must also be addressed using gender-transformative interventions. We also strongly suggest the creation of a Male Condom Acceptability Scale to understand condom users' needs.

"Condoms Are Boring": Navigating Relationship Dynamics, Gendered Power, and Motivations for Condomless Sex Amongst Adolescents and Young People in South Africa

Condoms remain an important method for preventing HIV prevention and unintentional pregnancies, however their use in South Africa is sub-optimal. We analyzed survey data on reported condom use among 3009 sexually active adolescent girls and young women (AGYW) aged 15-24 years, and qualitative data from interviews and focus group discussions with 237 AGYW and 38 male peers. Our findings describe the current condom use landscape among adolescents and young people in South Africa, illustrating relationship dynamics, gendered power and notions of masculinity which influence condom negotiation and use in young heterosexual South Africans' sexual encounters.

Exploring Determinants of Condom Use among University Students in Sudan

Increasing numbers of university students in Sudan are at risk of contracting HIV because of their engagement in condomless sex. A comprehensive and culturally accepted condom promotion program could potentially reduce this threat substantially. However, little is known about the sociocognitive determinants of condom use in this population: information that is required to develop such HIV prevention programs. Therefore, in August 2014, we conducted 30 semi-structured individual interviews with male and female students (both currently sexually active and nonactive) to explore determinants of condom use based on the I-Change model. Data were analyzed using Nvivo 10. The results suggest that barriers to condom use among university students include misconceptions about condom use, negative attitudes toward condom use, lack of social support, low self-efficacy to use condoms, and poor action planning. Sexual health promotion should, therefore, address these aspects to successfully promote condom use among sexually active students and subsequently reduce the risk of HIV transmission.

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.

Gender role conflict and sexual health and relationship practices amongst young men living in urban informal settlements in South Africa

Qualitative research suggests that men's inability to achieve dominant forms of masculinity may be related to HIV-risk behaviours and intimate partner violence (IPV) perpetration. Using clustered cross-sectional data, we assessed how young men's gender role conflict was associated with HIV-risk behaviours in urban informal settlements in KwaZulu-Natal, South Africa. Gender Role Conflict and Stress (GRC/S) was measured using a South African adaptation of the GRC/S scale comprising three sub-scales: subordination to women; restrictive emotionality; and success, power and competition. In random-effect models adjusting for socio-demographics, we tested the relationship with GRC/S sub-scales and sexual health behaviours (transactional sex, use of sex workers, ≥2 main partners and ≥2 casual/once off partners), and relationship practices (relationship satisfaction, relationship control, partnership type and perpetration of IPV). Overall, 449 young men (median age = 25, Q1, Q3 = 23-28) were included in the analysis. Higher GRC/S scores, denoting more GRC/S, were associated with increased relationship control and increased odds of having ≥2 casual or one-off partners and engaging in transactional sex. We found differences in associations between each sub-scale and sexual health and relationship practices, highlighting important implications for informing both theoretical understandings of masculinity and gender transformative efforts.

Factors associated with HIV in younger and older adult men in South Africa: findings from a cross-sectional survey

OBJECTIVE

This study investigated the behavioural, psychosocial and biological factors associated with HIV in a younger group of men (15 to 24 years) compared with an older group of men (25 to 35 years).

DESIGN

A household-based, cross-sectional study was conducted.

SETTING

Men were randomly selected using a two-stage random sampling method in KwaZulu-Natal, South Africa, between June 2014 and June 2015.

PARTICIPANTS

Overall, we interviewed 1472 younger men and 1138 older men. Only participants who could speak English or Zulu, were able to provide informed consent and who were expected to be living in the study area for the next 12 months were enrolled into the study.

PRIMARY AND SECONDARY OUTCOMES

HIV status was the primary outcome for the study. Men's HIV status was derived from blood samples collected in the study which were tested for HIV antibodies.

RESULTS

HIV prevalence was higher among older men (35.4%, 95% CI: 31.7 to 39.1) than younger men (7.6%, 95% CI: 6.2 to 9.4, p<0.01). Older men, who completed secondary school had a lower likelihood of being HIV positive (adjusted OR (AOR): 0.41, 95% CI: 0.27 to 0.63, p<0.001) and those with greater food insecurity had a higher likelihood of being HIV positive (AOR: 1.57, 95% CI: 1.05 to 2.34, p=0.04). Younger men with a higher number of lifetime sexual partners had a higher likelihood of being HIV positive (AOR: 1.04, 95% CI: 0.99 to 1.09, p=0.09).

CONCLUSION

Given that the HIV prevalence is higher in the older men, community based interventions need to target older men for medical circumcision and support HIV positive men to improve their material conditions early. For younger men intervening to reduce HIV risk behaviours at a young age before these behaviours become entrenched should be central to HIV prevention programmes.

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.

Effectiveness of a Health Behavioural Intervention Aimed at Reduction of Risky Sexual Behaviours among Young Men in the KwaZulu-Natal Province, South Africa

Two studies evaluating the same behavioural intervention were conducted in two areas in the KwaZulu-Natal province of South Africa using a randomized pre-test post-test control group design for study 1 (peri-urban) and a pre-test post-test design without a control group for study 2 (rural). The intervention included discussions and skills training on: (1) notions of masculinity, manhood, and responsibility, (2) personal and sexual relationships, (3) general communication skills, and (4) alcohol and other substance use. The intervention was aimed at men between 18 and 35 years of age. Measures of attitude, subjective norms, perceived behavioural control and intention for condom use, human immunodeficiency virus (HIV) testing, reduction of alcohol and drug use, avoiding sex while intoxicated, and avoiding sex with intoxicated people were assessed using a facilitator-administered questionnaire. The results for study 1 showed that 4 of the 19 variables scored significantly different at baseline and that all 19 variables showed no significant changes between pre-test and post-test. For study 2, one significant difference was found for attitude towards avoiding sex when one is intoxicated. Overall, the intervention had minimal success with just one area of positive effect. Further development and testing of this programme is recommended before it can be considered for broader scale implementation.

Determinants of risky sexual behaviours among adolescents in Central African Republic, Eswatini and Ghana: evidence from multi-indicator cluster surveys

Despite the declining HIV/AIDS prevalence globally, nearly half of all new HIV infections still occur among youth, especially in sub-Saharan Africa. While determinants of risky sexual behaviour have received copious attention in the literature, we still lack multi-country studies that track regional changes in sexual risk among youth in sub-Saharan Africa. This study seeks to fill part of this gap by identifying the determinants of risky sexual behaviours among adolescents in Ghana, Central African Republic (CAR) and Eswatini (formerly Swaziland). We used nationally representative sample data from the Multi Indicator Cluster survey, round four (MICS4). Results of the descriptive analysis show that overall consistent condom use is still extremely low in sub-Saharan Africa. In Ghana, only 8.5% of male youth and 7% of female youth consistently use condoms. In CAR this figure is 8% and 4% in male youth and female youth respectively. In Eswatini, with one of highest HIV prevalence in the world, the prevalence of consistent condom use is at 29% in males and 20% in females, higher than both in Ghana and CAR. Results of hierarchical models show that age at first sex does not predict risky sexual behaviour in Ghana, but it does predict risky sexual behaviour in CAR although only among young males. In Swaziland, age at first sex predicts risky sexual behaviour in both male and female youth but the relationship is not in the expected direction. Low socio-economic status predicts inconsistent condom use in all the three countries, but only among young females. This paper provides relevant policy lessons and recommendations.

HIV incidence and predictors of inconsistent condom use among adult men enrolled into an HIV vaccine preparedness study, Rustenburg, South Africa

INTRODUCTION

Understanding HIV incidence and risk behaviour among populations being considered for HIV vaccine studies is necessary for the appropriate design of trials.

METHODS

Between May 2012 and June 2015, we recruited men aged 18-49 years from urban and peri-urban areas of Rustenburg, a mining town in the North West Province, South Africa. Men who reported HIV-risk behaviour were followed for nine to 12 months to determine HIV incidence and factors associated with condom use.

RESULTS

A total of 400 HIV uninfected men were enrolled; 366 (91.5%) had at least one follow-up visit and were included in the analysis; 47.6% were under 25 years of age. HIV incidence was 1.9 per 100 person-years (95% CI: 0.79-4.56). Among heterosexual men (N = 339), 80.8% reported having vaginal intercourse with multiple partners in the past three months, among whom 74.1% reported inconsistent condom use. Sixty-eight percent reported vaginal intercourse with new female partners, of whom 40.6% reported inconsistent condom use. Over half (55.6%) of men who had sex with men (N = 27) reported anal intercourse with multiple male partners in the past three months, of whom 68.2% reported using condoms inconsistently. Men who had more than two female partners in the last three months (n = 121) were more likely to use condoms inconsistently (aOR 4.31, 95% CI: 1.34-13.8); in contrast, those with more than one new female sex partner (aOR 0.13, 94% CI 0.04-0.44), and whose sexual debut was after 19 years of age (aOR 0.39, 95% CI: 0.15-1.01) were less likely to use condoms inconsistently.

CONCLUSION

HIV incidence was low and similar to other studies of heterosexual men in South Africa. To identify men at high risk for HIV for enrolment in prevention trials, future researchers may need to focus on those who report early sexual debut and who report having multiple sexual partners. Men in newer relationships appear to use condoms more frequently.

The protective role of family structure for adolescent development in sub-Saharan Africa

Several studies have focused on the risk factors associated with adolescent developmental outcomes, but the literature on the role of protective factors at the family and community level for positive adolescent development is scarce, especially in sub-Saharan Africa (SSA). We hypothesize that ensuring a supportive environment for adolescents may result in delayed sexual debut for adolescents in SSA. The relationship between family structure and positive adolescent sexual behaviour, measured as delay in sexual debut, was examined using the bioecological theory framed by a risk and resilience perspective. We used nationally representative data on female and male adolescents (aged 15–17 years) from 12 countries in SSA. We modelled logistic regressions to test for associations between family structure and delayed sexual debut while controlling for other covariates in SSA. The majority (90%) of the young adults delayed sexual debut, and this delay varied by family structure. After controlling for other covariates, adolescents living with neither parent had lower odds of delaying sexual debut although results were only significant for males. Interaction terms with community socio-economic status showed an interaction between community education and males living with neither parent. Future studies must investigate the gender differentials in the relationship between family structure and delayed sexual debut among adolescents in SSA.

Sexual Quality of Life and Association With HIV and Sexually Transmitted Infections Among a Cohort of Heterosexual Couples in Kenya

INTRODUCTION

Sexual quality of life (SQoL) is a critical component of sexual health and is understudied in Sub-Saharan African settings with endemic HIV and sexually transmitted infection (STI).

AIM

We sought to assess SQoL among heterosexual couples in Kisumu, Kenya, and how this was associated with HIV status, STIs, and sexual practices.

METHODS

This was a prospective cohort study of community-recruited couples. SQoL, HIV status, herpes simplex virus (HSV)-2 status, bacterial vaginosis (BV), sexual practices, and sociodemographics were measured at baseline, 6 months, and 12 months. Multivariable linear regression with random intercept was fitted separately for females and males, accounting for partner characteristics.

MAIN OUTCOME MEASURE

SQoL was assessed with an 18-item female and 11-item male survey.

RESULTS

From April 2014 through July 2016, 252 couples were enrolled, and followed up through September 2017. At baseline, women were median age 23 years, 10% HIV positive, 53% HSV-2 seropositive, and 22% with BV. At baseline men were median age 26 years, 12% HIV positive, 47% HSV-2 seropositive, and 56% circumcised. Mean SQoL was higher for men (88) than women (78), with consistent scores over time. In multivariable analysis (P < .05 each), SQoL Questionnaire-Female (SQoL-F) score was reduced with: male partner report that sex felt rougher than he would have liked (9.5-point decrease), female HSV-2 seropositivity (5.15-point decrease), female reported having dry vaginal sex (5.27-point decrease); among women with BV, SQoL-F score declined with recent sexual activity (8.27-point decrease) and increasing age (0.75-point decrease per 1 year increase in age). Age and recent sex did not affect SQoL-F for women without BV. SQoL Questionnaire-Male score was decreased 4.99 points if male was employed, 4.52 points if male reported multiple recent sex partners, and 29.5 points for HIV positive men whose female partner reported having sex when not in the mood. Men's SQoL increased by 0.84 points for each 1-U increase in female partner body mass index and 17.6 points for HIV positive men whose female partner reported recent sex with him.

CLINICAL IMPLICATIONS

Within sexual partnerships, men had greater SQoL than women, and the adverse impact of BV and STIs on SQoL was greater for women than men.

STRENGTH & LIMITATIONS

Research is needed to ensure relevant domains are measured in settings where measure of SQoL has not been validated, along with robust measures of physiologic and psychologic correlates.

CONCLUSION

More attention to SQoL as an outcome may strengthen interventions aimed at preventing HIV and STIs and improving sexual health holistically. Mehta SD, Nordgren RK, Agingu W, et al. Sexual Quality of Life and Association With HIV and Sexually Transmitted Infections Among a Cohort of Heterosexual Couples in Kenya. J Sex Med 2018;15:1446-1455.

The theory of masculinity in studies on HIV. A systematic review

This study aimed to describe the methodological characteristics of publications on HIV and masculinity, to identify possible information gaps and determine the main thematic areas. A systematic review was conducted of gender, masculinity, HIV infection and other sexually-transmitted infections in original articles published between 1992 and 2015. Original studies published from Pubmed and Scopus were included. A total of 303 articles were identified, of which 187 were selected. Most of the studies were qualitative and the most widely used technique was the interview. Twenty-nine-point five percent of studies were performed in South Africa, 20.8% in the USA, and 3.2% in Europe. Fifteen percent of the studies were performed in heterosexuals, 12.8% in men who have sex with men, and 60% did not specify the sexual orientation of the population. Eight thematic areas were defined, the most frequent being sexuality and risk behaviours, defined by men's need to demonstrate they were sexually active and a breadwinner. Most studies on HIV and masculinity show a gender bias by not specifying the sexual identity of the population. Studies should consider diversity in sexual and cultural identity in different contexts, including in Europe, to carry out more effective HIV interventions from a masculinity perspective.

What motivates serodiscordant couples to prevent HIV transmission within their relationships: findings from a PrEP implementation study in Kenya

With the planned scale-up of pre-exposure prophylaxis (PrEP) for HIV prevention among serodiscordant couples in resource-limited settings, gaining an understanding of what motivates serodiscordant couples to prevent HIV is critical. We conducted 44 semi-structured, in-depth individual or couple interviews with 63 participants (33 HIV-infected and 30 HIV-uninfected participants) enrolled in a prospective implementation study of oral antiretroviral-based prevention in Kisumu, Kenya. Transcripts were iteratively analysed using inductive content analysis. Findings point to the importance of maintaining the emotional and economic stability of the partnership and family as motivators in preventing HIV transmission. Female participants identified fear of blame or potential violence for transmitting HIV as a motivator. Furthermore, couples primarily held the HIV-infected individual responsible for HIV prevention, but also held women more accountable for the use of prevention methods such as condoms. These themes substantiate traditional gender norms but also reveal how dyadic interdependence challenges these norms. As programmes in resource-limited settings scale up PrEP access, they should simultaneously capitalise on HIV serodiscordant couples' motivations for HIV prevention and address gender norms so women do not find themselves unduly responsible for the prevention of HIV transmission.

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.

Girls cannot be trusted: young men's perspectives on contraceptive decision making and sexual relationships in Bolgatanga, Ghana

BACKGROUND

There is extensive research on African girls sexual experiences, but much less is known about boys thoughts and actions. There is a need to understand the male perspective in order to develop sexuality education programmes that address the high rates of teenage pregnancy and sexually transmitted infections in sub-Saharan Africa.

METHODS

For this qualitative, phenomenological study we spoke to 20 boys from Bolgatanga, Ghana and explored their sexual decision making, using semi-structured interviews designed to highlight psychosocial and environmental factors. Content analysis was used to construct categories and later the themes.

RESULTS

Boys often had negative perceptions about sexual relationships. They believed that girls could not be trusted and mostly embarked on sexual relationships for material gain. The boys reported engaging in multiple sexual partnerships to secure their masculine status; however, they expected girls to be 'faithful'. We found that accurate knowledge of safe sex was lacking, boys were under peer pressure to conform to beliefs about masculinity and communication about sex mainly took place within peer groups.

CONCLUSIONS

There is a need to emphasise condom use in established relationships. There should also be more discussion of issues surrounding fidelity and gender equality, as part of sexuality programmes aimed at boys in Ghana and in similar cultures.

Gender, Sexual Self-Efficacy and Consistent Condom Use Among Adolescents Living in the HIV Hyper-Endemic Setting of Soweto, South Africa

Within HIV-endemic settings, few studies have examined gendered associations between sexual self-efficacy (SSE), one's confidence or perceived control over sexual behavior, and uptake of HIV prevention behaviors. Using cross-sectional survey data from 417 sexually-experienced adolescents (aged 14-19, median age = 18, 60% female) in Soweto, South Africa, we measured SSE using a 6-item scale (range:0-6) with 'high-SSE' = score > 3 (study alpha = 0.75). Gender-stratified logistic regression models assessed associations between high-SSE and lifetime consistent condom use. A higher proportion of women reported high-SSE (68.7%) than men (49.5%, p < 0.001). We observed no difference in reported consistent condom use by gender (45.5% among women, 45.8% among men; p = 0.943). In confounder models, high-SSE was associated with consistent condom use among men (aOR = 3.51, 95%CI = 1.86-6.64), but not women (aOR = 1.43, 95%CI = 0.74-2.77). Findings highlight that individual-level psychosocial factors are insufficient for understanding condom use and must be considered alongside the relational, social, and structural environments within which young women navigate their sexual lives.

Ethnicity, gender and risky sexual behaviour among Nigeria youth: an alternative explanation

BACKGROUND

While studies in demography and public health have acknowledged the role of ethnic differences, the influence of ethnicity on youth sexual behaviour in Nigeria has received little or no attention. It is important to know how cultural norms and gender roles, which vary by ethnicity, may promote or prevent risky behaviour. Such information could provide insights into previously undetected sexual behaviour in multi-ethnic situations.

METHODS

The Nigeria Demographic and Health Surveys (NDHS) for 2003, 2008 and 2013 were pooled to examine the relationship between ethnicity and youth sexual reproductive health, proxied by age at sexual debut, multiple sexual partners (MSP) and condom use at last sexual activity, among the 6304 females and 1549 males who reported being sexually active in the four weeks preceding the survey. Multivariate analysis using a Cox proportional hazard regression model was used to determine the risk factors for early sexual activity among young people (15-24). Logistic regression was used to predict condom use at last sexual activity and MSP.

RESULTS

The median age at first sexual activity was 16 for females and 17 for males. 43% of male youths used condoms in their last sexual activity, compared to only 16% among females and a higher number of males (81%) had multiple sexual partners compared to females (35%). For females, elevated risks of first sex was higher among Hausa/Fulanis aged 15-19 and elevated risk of first sex was higher among Yoruba males.

CONCLUSION

This study provides further evidence that in order to promote protective sexual behaviours among youth in Nigeria, social, cultural and gender-specific tactics should be put in place for the prevention of HIV and other STIs.

'If they have a girlfriend, they have five girlfriends': Accountability and sexism in volunteer workers' talk about HIV/AIDS in a South African health setting

Significant challenges remain in tackling the global HIV/AIDS epidemic. Effective action requires both appropriate policy at a global level and informed practice on the local level. Here, we report how workers in a project in Johannesburg, South Africa, make sense of HIV transmission. Discourse analysis of data from interviews with 63 participants shows that project workers routinely attribute transmission to men's sexual relationships with multiple female partners. This explanation is so pervasive that it renders invisible other routes to transmission. Absence of consideration of other routes to infection potentially restricts front-line practice, so hindering local attempts to tackle HIV/AIDS.

Masculinity and HIV: Dimensions of Masculine Norms that Contribute to Men's HIV-Related Sexual Behaviors

Numerous studies have documented a relationship between masculine norms and men's HIV-related sexual behaviors, but intervening upon this relationship requires a nuanced understanding of the specific aspects of masculine norms that shape men's sexual behaviors. We integrate theories on masculinities with empirical HIV research to identify specific dimensions of masculine norms that influence men's HIV-related sexual behaviors. We identify three major dimensions of masculine norms that shape men's sexual behavior: (1) uncontrollable male sex drive, (2) capacity to perform sexually, and (3) power over others. While the existing literature does help explain the relationship between masculine norms and men's sexual behaviors several gaps remain including: a recognition of context-specific masculinities, an interrogation of the positive influences of masculinity, adoption of an intersectional approach, assessment of changes in norms and behaviors over time, and rigorous evaluations of gender-transformative approaches. Addressing these gaps in future research may optimize prevention efforts.

Gendered power dynamics and women's negotiation of family planning in a high HIV prevalence setting: a qualitative study of couples in western Kenya

In sub-Saharan Africa, high burdens of HIV and unmet need for contraception often coexist. Research emphasises the need to engage men and couples in reproductive health, yet couples' negotiations around fertility and family planning in the context of HIV have been sparsely studied. This study examined the gendered power dynamics that frame women's and couples' negotiations of contraceptive use in western Kenya. We conducted 76 in-depth interviews with 38 couples, of whom 22 couples were concordant HIV-positive. Qualitative data were analysed using a grounded theory approach. Direct communication around contraception with men was often challenging due to perceived or expressed male resistance. A substantial minority of women avoided male reproductive decision-making authority through covert contraceptive use, with concern for severe consequences when contraceptive use was discovered. Many men assumed that family planning use signified female promiscuity and that infidelity motivated covert use. Men were more willing to use condoms to avoid HIV re-infection or on the recommendation of HIV care providers, which allowed some women leverage to insist on condom use. Our findings highlight the tension between male dominated reproductive decision making and women's agency and point to the need for gender transformative approaches seeking to challenge masculinities that negatively impact health.

Optimizing HIV prevention for women: a review of evidence from microbicide studies and considerations for gender-sensitive microbicide introduction

Introduction

Microbicides were conceptualized as a product that could give women increased agency over HIV prevention. However, gender-related norms and inequalities that place women and girls at risk of acquiring HIV are also likely to affect their ability to use microbicides. Understanding how gendered norms and inequalities may pose obstacles to women's microbicide use is important to inform product design, microbicide trial implementation and eventually microbicide and other antiretroviral-based prevention programmes. We reviewed published vaginal microbicide studies to identify gender-related factors that are likely to affect microbicide acceptability, access and adherence. We make recommendations on product design, trial implementation, positioning, marketing and delivery of microbicides in a way that takes into account the gender-related norms and inequalities identified in the review.

Methods

We conducted PubMed searches for microbicide studies published in journals between 2000 and 2013. Search terms included trial names (e.g. “MDP301”), microbicide product names (e.g. “BufferGel”), researchers’ names (e.g. “van der Straten”) and other relevant terms (e.g. “microbicide”). We included microbicide clinical trials; surrogate studies in which a vaginal gel, ring or diaphragm was used without an active ingredient; and hypothetical studies in which no product was used. Social and behavioural studies implemented in conjunction with clinical trials and surrogate studies were also included. Although we recognize the importance of rectal microbicides to women, we did not include studies of rectal microbicides, as most of them focused on men who have sex with men. Using a standardized review template, three reviewers read the articles and looked for gender-related findings in key domains (e.g. product acceptability, sexual pleasure, partner communication, microbicide access and adherence).

Results and discussion

The gendered norms, roles and relations that will likely affect women's ability to access and use microbicides are related to two broad categories: norms regulating women's and men's sexuality and power dynamics within intimate relationships. Though norms about women's and men's sexuality vary among cultural contexts, women's sexual behaviour and pleasure are typically less socially acceptable and more restricted than men's. These norms drive the need for woman-initiated HIV prevention, but also have implications for microbicide acceptability and how they are likely to be used by women of different ages and relationship types. Women's limited power to negotiate the circumstances of their intimate relationships and sex lives will impact their ability to access and use microbicides. Men's role in women's effective microbicide use can range from opposition to non-interference to active support.

Conclusions

Identifying an effective microbicide that women can use consistently is vital to the future of HIV prevention for women. Once such a microbicide is identified and licensed, positioning, marketing and delivering microbicides in a way that takes into account the gendered norms and inequalities we have identified would help maximize access and adherence. It also has the potential to improve communication about sexuality, strengthen relationships between women and men and increase women's agency over their bodies and their health.

Prevalence and correlates of intimate partner violence in HIV-positive women engaged in transactional sex in Mombasa, Kenya

We evaluated the prevalence and correlates of intimate partner violence (IPV) in the past year by a regular male partner in HIV-positive female sex workers (FSWs) in Mombasa, Kenya. This cross-sectional study included HIV-positive women ≥18 years old who reported engagement in transactional sex at the time of enrolment in the parent cohort. We asked 13 questions adapted from the World Health Organization survey on violence against women about physical, sexual, or emotional violence in the past year by the current or most recent emotional partner (index partner). We used standardised instruments to assess socio-demographic and behavioural characteristics as possible correlates of IPV. Associations between IPV and these correlates were evaluated using univariate and multivariate logistic regression. Overall, 286/357 women (80.4%) had an index partner, and 52/357 (14.6%, 95% confidence interval 10.9%-18.2%) reported IPV by that partner in the past year. In multivariate analysis, women with severe alcohol problems (adjusted odds ratio 4.39, 1.16-16.61) and those experiencing controlling behaviours by the index partner (adjusted odds ratio 4.98, 2.31-10.74) were significantly more likely to report recent IPV. Recent IPV was common in HIV-positive FSWs. Interventions targeting risk factors for IPV, including alcohol problems and partner controlling behaviours, could help to reduce recurrent violence and negative health outcomes in this key population.

Sexual communication self-efficacy, hegemonic masculine norms and condom use among heterosexual couples in South Africa

Hegemonic masculine norms (HMN), which promote sexual risk-taking among males and the subordination of women, are believed to play a key role in the HIV epidemic among heterosexual couples in South Africa (SA). Sexual communication self-efficacy (SCSE) (i.e., a couple's confidence in their ability to communicate about HIV prevention) may be a key leverage point for increasing HIV prevention behaviors among this population. We interviewed 163 sexually active heterosexual couples in Soweto, SA to investigate the association between SCSE, HMN, and consistent condom use. We collected information on demographics, relationship dynamics, and sexual activity. We utilized the SCSE scale to measure couples' SCSE, and a subscale of the Gender Equitable Men scale to measure HMN among males. We performed bivariate and multivariable analyses to determine the association of consistent condom use with couples' SCSE as well as the male partner's endorsement of HMN. We found that couples with higher SCSE have greater odds of consistent condom use (adjusted odds ratio [AOR] = 1.30, 95% CI: 1.15-1.47). Furthermore, male endorsement of HMN was found to be negatively associated with consistent condom use among couples (AOR = 0.47, 95% CI: 0.24-0.89). Joint HIV serostatus was not significantly associated with the outcome. Future interventions that equip heterosexual couples with sexual communication skills, while simultaneously promoting more gender equitable norms, may increase consistent condom use and thereby reduce the transmission of HIV among this at-risk population.

Why do men often not use condoms in their relationships with casual sexual partners in Uganda?

With a focus on Uganda, this paper examines men's condom use in sexual relationships with casual partners and what this might tell us about men's vulnerability to HIV-infection. We carried out repeat interviews with 31 men attending a clinic serving women at high risk for HIV infection and their partners in Kampala. We found that the experience of condom-less sex in the men's youth, itself the outcome of a restrictive home environment, was perceived as influencing later unsafe sexual behaviour. Peer pressure encouraged men to have multiple partners. Alcohol negatively affected condom use. Men often opted not to use a condom with women they thought looked healthy, particularly if they had had sex with the same woman before. Some men who were HIV-positive said they saw little point in using condoms since they were already infected. A concerted effort is required to reach men, like those in our study, to halt HIV and the transmission of other sexually transmitted infections.

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.

Sexual violence, condom negotiation, and condom use in the context of sex work: results from two West African countries

BACKGROUND

Female sex workers (FSWs) are vulnerable to violence within and beyond the workplace. Violence is associated with increased burden of HIV, possibly explained through physiologic or behavioral causal pathways. These analyses sought to determine the relationship between lifetime sexual violence with unprotected, condomless vaginal intercourse (UVI) among FSWs in West Africa.

METHODS

FSWs (aged ≥18 years) were recruited into a cross-sectional study through respondent-driven sampling in two West African countries, Togo and Burkina Faso. A total of 1380 participants were enrolled from January to July 2013, and completed a sociobehavioral questionnaire and HIV testing. Measures included sex work history, lifetime experiences of violence victimization, sexual practices, and UVI (past month). Crude and adjusted robust log binomial regression was conducted to estimate prevalence ratios (PrR) as a measure of association between UVI with clients and the primary exposure, forced sex.

RESULTS

Self-reported lifetime physical abuse (47.3%), forced sex (33.0%), and any violence (57.9%) were common. Almost one-quarter (23.9%) reported recent UVI with clients. History of forced sex was independently associated with recent UVI with clients [vs. none, adjusted PrR: 1.49; 95% confidence interval (CI): 1.18 to 1.88], with evidence of partial mediation by difficult condom negotiation with regular (aPrR: 1.83; 95% CI: 1.43 to 2.34) and new clients (aPrR: 1.60; 95% CI: 1.13 to 2.29).

DISCUSSION

These data demonstrate the significant relationship between sexual violence experienced by FSWs and unprotected sex with clients. Comprehensive interventions reducing vulnerabilities to violence combined with improved condom negotiation are needed to address the complex influences of condom use during sex work as a means of ultimately lowering HIV acquisition and transmission.

Gender norms, poverty and armed conflict in Côte D'Ivoire: engaging men in women's social and economic empowerment programming

Engaging men is a critical component in efforts to reduce intimate partner violence (IPV). Little is known regarding men's perspectives of approaches that challenge inequitable gender norms, particularly in settings impacted by armed conflict. This article describes men's experiences with a women's empowerment program and highlights men's perceptions of gender norms, poverty and armed conflict, as they relate to achieving programmatic goals. Data are from 32 Ivorian men who participated in indepth interviews in 2012. Interviews were undertaken as part of an intervention that combined gender dialogue groups for both women and their male partners with women's only village savings and loans programs to reduce IPV against women. Findings suggested that in the context of armed conflict, traditional gender norms and economic stressors experienced by men challenged fulfillment of gender roles and threatened men's sense of masculinity. Men who participated in gender dialogue groups discussed their acceptance of programming and identified improvements in their relationships with their female partners. These men further discussed increased financial planning along with their partners, and attributed such increases to the intervention. Addressing men's perceptions of masculinity, poverty and armed conflict may be key components to reduce men's violence against women in conflict-affected settings.

“I Don’t Shag Dirty Girls”

Understanding and addressing the sexual risk taking of young men remains a key research, policy, and practice concern in attempts to improve the emotional and physical sexual health of young men and their sexual partners. This article explores one of the ways in which young men attempt to mitigate sexual risk through the assigning of labels to particular young women and using these as a basis for their decisions in relation to sexual activity, contraception, and condom use. The article uses the lens of hegemonic masculinities theory to increase understanding of the role played by the construction and performance of marginalized masculinities and how these in turn are influenced by social exclusionary processes. The article draws on focus group and interview data from 46 young men aged 15 to 17 years living in the northwest of England, purposively selected on the basis of the prevailing policy definitions of social inclusion and exclusion. The article describes a form of marginalized masculinity pertaining to socially excluded young men, which as a result of limited access to other tenets of hegemonic masculinity, is disproportionately reliant on sexual expertise and voracity alongside overt demonstrations of their superiority over women. It is in this context that young women are assigned the labels of “dirty” or “clean” on the basis of a selection of arbitrary judgments relating to dress, demeanor, area of residence, and perceived sexual activities. The motivations of the young men, the impact on young women, and the policy and practice implications are all discussed.

Reconstructing masculinity? A qualitative evaluation of the Stepping Stones and Creating Futures interventions in urban informal settlements in South Africa

Evidence shows the importance of working with men to reduce intimate partner violence and HIV-risk. Two claims dominate this work. The first is that interventions 'reconstruct' masculinities--these new formations of masculinity exist in opposition to existing ones and are healthier for men and less harmful for women. The second is that to be successful, such interventions need to address men's exclusion from the economy. Using a qualitative longitudinal cohort study of young men who participated in a gender transformative and livelihood strengthening intervention, as well as dyadic interviews with men's main female partners, we explore these claims. Data suggests men saw some improvements in livelihoods and relationships. However, challenging social contexts, including high rates of unemployment, peer networks and a dominant youth masculinity, limited change. Rather than reconstructing masculinity, a more subtle shift was seen with men moving away from 'harmful' aspects of a dominant youth masculinity towards a form of masculinity whereby male power is buttressed by economic provision and attempting to form and support 'households'. Working with men on their livelihoods at an instrumental level encouraged participation in the intervention. Beyond encouragement, men's improving livelihoods afforded men the opportunity to materially demonstrate the social changes - in the form of shifts in masculinity--they were seeking to enact.

Protective factors and HIV risk behavior among South African men

The primary mode of HIV transmission in South Africa is heterosexual sexual behavior. HIV prevention research specifically focusing on men in South Africa is limited. We assessed self-reported HIV risk behaviors in 1,181 men ages 18 to 45 years in randomly selected neighborhoods in Eastern Cape Province, South Africa. Older men were less likely to report having multiple partners. Religiosity was a protective factor for condom use and unprotected sex with steady partners. Discussing using condoms was a protective factor for condom use and unprotected sex with both steady and casual partners. Having a child was associated with decreased condom use with steady partners and employment was associated with decreased condom use with casual partners. The findings suggest the need for HIV risk-reduction behavioral interventions tailored for South African men with regard to age, religiosity, and types of sexual partners. Implications for the development of such interventions are discussed.

A descriptive analysis of perceptions of HIV risk and worry about acquiring HIV among FEM-PrEP participants who seroconverted in Bondo, Kenya, and Pretoria, South Africa

INTRODUCTION

Risk perception is a core construct in many behaviour change theories in public health. Individuals who believe they are at risk of acquiring an illness may be more likely to engage in behaviours to reduce that risk; those who do not feel at risk may be unlikely to engage in risk reduction behaviours. Among participants who seroconverted in two FEM-PrEP sites - Bondo, Kenya, and Pretoria, South Africa - we explored perceived HIV risk and worry about acquiring HIV prior to HIV infection.

METHODS

FEM-PrEP was a phase III clinical trial of once-daily, oral emtricitabine and tenofovir disoproxil fumarate for HIV prevention among women in sub-Saharan Africa. We asked all participants about their perceived HIV risk in the next four weeks, prior to HIV testing, during a quantitative face-to-face interview at enrolment and at quarterly follow-up visits. Among participants who seroconverted, we calculated the frequencies of their responses from the visit conducted closest to, but before, HIV acquisition. Also among women who seroconverted, we conducted qualitative, semi-structured interviews (SSIs) at weeks 1, 4 and 8 after participants' HIV diagnosis visit to retrospectively explore feelings of HIV worry. Applied thematic analysis was used to analyse the SSI data.

RESULTS

Among participants who seroconverted in Bondo and Pretoria, 52% reported in the quantitative interview that they had no chance of acquiring HIV in the next four weeks. We identified four processes of risk rationalization from the SSI narratives. In "protective behaviour," participants described at least one risk reduction behaviour they used to reduce their HIV risk; these actions made them feel not vulnerable to HIV, and therefore they did not worry about acquiring the virus. In "protective reasoning," participants considered their HIV risk but rationalized, based on certain events or beliefs, that they were not vulnerable and therefore did not worry about getting HIV. In "recognition of vulnerability," participants described reasons for being worried about getting HIV but said no or limited action was taken to reduce their perceived vulnerability. Participants with "no rationalization or action" did not describe any HIV worry or did not engage in HIV risk reduction behaviours.

CONCLUSIONS

Women who are at substantial risk of acquiring HIV may underestimate their actual risk. Yet, others who accurately understand their HIV risk may be unable to act on their concerns. Perceived HIV risk and risk rationalization are important concepts to explore in risk reduction counselling to increase the use of HIV prevention strategies among women at risk of HIV.