Structural approaches to HIV prevention.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)30003-X.pdf

Syndemics and the biosocial conception of health

Introduction : At the epicentre of the HIV epidemic in southern Africa, adolescent girls and young women aged 15–24 contribute a disproportionate ~30% of all new infections and seroconvert 5–7 years earlier than their male peers. This age–sex disparity in HIV acquisition continues to sustain unprecedentedly high incidence rates, and preventing HIV infection in this age group is a pre-requisite for achieving an AIDS-free generation and attaining epidemic control. Discussion : Adolescent girls and young women in southern Africa are uniquely vulnerable to HIV and have up to eight times more infection than their male peers. While the cause of this vulnerability has not been fully elucidated, it is compounded by structural, social and biological factors. These factors include but are not limited to: engagement in age-disparate and/or transactional relationships, few years of schooling, experience of food insecurity, experience of gender-based violence, increased genital inflammation, and amplification of effects of transmission co-factors. Despite the large and immediate HIV prevention need of adolescent girls and young women, there is a dearth of evidence-based interventions to reduce their risk. The exclusion of adolescents in biomedical research is a huge barrier. School and community-based education programmes are commonplace in many settings, yet few have been evaluated and none have demonstrated efficacy in preventing HIV infection. Promising data are emerging on prophylactic use of anti-retrovirals and conditional cash transfers for HIV prevention in these populations. Conclusions : There is an urgent need to meet the HIV prevention needs of adolescent girls and young women, particularly those who are unable to negotiate monogamy, condom use and/or male circumcision. Concerted efforts to expand the prevention options available to these young women in terms of the development of novel HIV-specific biomedical, structural and behavioural interventions are urgently needed for epidemic control. In the interim, a pragmatic approach of integrating existing HIV prevention efforts into broader sexual reproductive health services is a public health imperative. Keywords: HIV prevention; adolescent girls; young women; prevention interventions. (Published: 26 February 2015) Citation: Dellar RC et al. Journal of the International AIDS Society 2015, 18(Suppl 1) :19408 http://www.jiasociety.org/index.php/jias/article/view/19408 | http://dx.doi.org/10.7448/IAS.18.2.19408

https://onlinelibrary.wiley.com/doi/pdf/10.7448/IAS.18.2.19408

Adolescent girls and young women: key populations for HIV epidemic control

Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS

https://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(13)70074-3.pdf

Prevalence of and factors associated with male perpetration of intimate partner violence: findings from the UN Multi-country Cross-sectional Study on Men and Violence in Asia and the Pacific

Background 
Both food insufficiency and HIV infection are major public health problems in sub-Saharan Africa, yet the impact of food insufficiency on HIV risk behavior has not been systematically investigated. We tested the hypothesis that food insufficiency is associated with HIV transmission behavior.


Methods and Findings 
We studied the association between food insufficiency (not having enough food to eat over the previous 12 months) and inconsistent condom use, sex exchange, and other measures of risky sex in a cross-sectional population-based study of 1,255 adults in Botswana and 796 adults in Swaziland using a stratified two-stage probability design. Associations were examined using multivariable logistic regression analyses, clustered by country and stratified by gender. Food insufficiency was reported by 32% of women and 22% of men over the previous 12 months. Among 1,050 women in both countries, after controlling for respondent characteristics including income and education, HIV knowledge, and alcohol use, food insufficiency was associated with inconsistent condom use with a nonprimary partner (adjusted odds ratio [AOR] 1.73, 95% confidence interval [CI] 1.27–2.36), sex exchange (AOR 1.84, 95% CI 1.74–1.93), intergenerational sexual relationships (AOR 1.46, 95% CI 1.03–2.08), and lack of control in sexual relationships (AOR 1.68, 95% CI 1.24–2.28). Associations between food insufficiency and risky sex were much attenuated among men.


Conclusions 
Food insufficiency is an important risk factor for increased sexual risk-taking among women in Botswana and Swaziland. Targeted food assistance and income generation programs in conjunction with efforts to enhance women's legal and social rights may play an important role in decreasing HIV transmission risk for women.

/pdf/food-insufficiency-is-associated-with-high-risk-sexual-34xxn9m5ld.pdf

Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland

Background 
There is limited empirical research on the underlying gender inequity norms shaping gender-based violence, power, and HIV risks in sub-Saharan Africa, or how risk pathways may differ for men and women. This study is among the first to directly evaluate the adherence to gender inequity norms and epidemiological relationships with violence and sexual risks for HIV infection.


Methods 
Data were derived from population-based cross-sectional samples recruited through two-stage probability sampling from the 5 highest HIV prevalence districts in Botswana and all districts in Swaziland (2004–5). Based on evidence of established risk factors for HIV infection, we aimed 1) to estimate the mean adherence to gender inequity norms for both men and women; and 2) to model the independent effects of higher adherence to gender inequity norms on a) male sexual dominance (male-controlled sexual decision making and rape (forced sex)); b) sexual risk practices (multiple/concurrent sex partners, transactional sex, unprotected sex with non-primary partner, intergenerational sex).


Findings 
A total of 2049 individuals were included, n = 1255 from Botswana and n = 796 from Swaziland. In separate multivariate logistic regression analyses, higher gender inequity norms scores remained independently associated with increased male-controlled sexual decision making power (AORmen = 1.90, 95%CI:1.09–2.35; AORwomen = 2.05, 95%CI:1.32–2.49), perpetration of rape (AORmen = 2.19 95%CI:1.22–3.51), unprotected sex with a non-primary partner (AORmen = 1.90, 95%CI:1.14–2.31), intergenerational sex (AORwomen = 1.36, 95%CI:1.08–1.79), and multiple/concurrent sex partners (AORmen = 1.42, 95%CI:1.10–1.93).


Interpretation 
These findings support the critical evidence-based need for gender-transformative HIV prevention efforts including legislation of women's rights in two of the most HIV affected countries in the world.

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0028739&type=printable

Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland.

Objectives. We sought to identify correlates of forced sex perpetration among men and victimization among women in Botswana and Swaziland.Methods. We surveyed a 2-stage probability sample of 2074 adults from the 5 districts of Botswana with the highest HIV prevalence rates and all 4 regions of Swaziland. We used multivariable logistic regression to identify correlates of forced sex victimization and perpetration.Results. Lifetime prevalence rates of forced sex victimization of women were 10.3% in Botswana and 11.4% in Swaziland; among men, rates of perpetration were 3.9% in Botswana and 5.0% in Swaziland. Lifetime history of forced sex victimization was the strongest predictor of forced sex perpetration by men in Botswana (adjusted odds ratio [OR] = 13.70; 95% confidence interval [CI] = 4.55, 41.50) and Swaziland (adjusted OR = 5.98; 95% CI = 1.08, 33.10). Problem or heavy drinking was the strongest predictor of forced sex victimization among women in Botswana (adjusted OR = 2.55; 95% CI = 1.19, 5.49) and...

Zakhe Hlanze

Papers

Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland

Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland.

Prevalence and Correlates of Forced Sex Perpetration and Victimization in Botswana and Swaziland