HIV This Week

Gender asymmetry in healthcare-facility attendance of people living with HIV/AIDS in Burkina Faso.

Bila B, Egrot M. Soc Sci Med. 2009; 69:854-61

Anthropological research in Burkina Faso indicates that more HIV-positive women than HIV-positive men are attending care facilities for people living with HIV and accessing antiretroviral medicine. This article, situated in the field of study of interactions between gender and AIDS, offers a description of this asymmetry and an anthropological analysis of the socio-cultural determinants, through analysis of data from ethnographic research among people living with HIV and health actors. Examining social representations of femininity and masculinity in Burkinabe society and the organisation of the healthcare system in connection with gender shed light on the decision-making processes of both sexes around therapeutic choices and the itinerary of care. On the one hand, the social values attached to femininity, maternity and the status of wife create conditions for women that favour their attendance at care facilities for people living with HIV and encourage a widespread practice where wives take the place of their husbands in healthcare queues. Moreover, health policies and the effects of women’s empowerment within the healthcare system strengthen women’s access to health services. On the other hand, representations of masculinity are fully implicated in the cultural construction of men’s reluctance to attend care facilities for people living with HIV. The values associated with this masculinity cause men to run great health, economic and social risks, not only for themselves, but also for their wives and children. By better understanding the interaction between gender, the experience of HIV and the institutional organisation of healthcare, we can identify ways to reduce men’s reluctance to attend care facilities for people living with HIV and improve both prevention and treatment-oriented programmes.

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Editors’ note: This thoughtful article is an interesting read. Although the effects of gendered systems in sub-Saharan Africa create socioeconomic disadvantage and vulnerability for women compared to men, men are caught up in representations of masculinity that do not allow them to overcome their feelings of shame to seek care. These feelings centre both on having HIV infection and on needing external support for food, medicine and school supplies. In contrast, women’s feelings of obligation to be in good health so as to care for their children now and over the long-term motivate them to seek treatment, food, and school supply support readily at health care facilities. The result is that 2 men are followed clinically for every 3 to 6 women despite equivalent HIV prevalence. The solution is not separate service provision, although food support could be accessed at non-HIV care settings using vouchers, and is likely multi-faceted. Awareness raising focused on encouraging men living with HIV to value their social responsibility to their families and seek care might be a good start. 

Role of widows in the heterosexual transmission of HIV in Manicaland, Zimbabwe, 1998-2003. Lopman BA, Nyamukapa C, Hallett TB, Mushati P, Spark-du Preez N, Kurwa F, Wambe M, Gregson S. Sex Transm Infect. 2009 85 Suppl 1:i41-8.

AIDS is the main driver of young widowhood in southern Africa. The demographic characteristics of widows, their reported risk behaviours, and the prevalence of HIV were examined by analysing a longitudinal population-based cohort of men and women aged 15-54 years in Manicaland, eastern Zimbabwe. The results from statistical analyses were used to construct a mathematical simulation model with the aim of estimating the contribution of widow behaviour to heterosexual HIV transmission. 413 (11.4%) sexually experienced women and 31 (1.2%) sexually experienced men were reported to be widowed at the time of follow-up. The prevalence of HIV was exceptionally high among both widows (61%) and widowers (male widows) (54%). Widows were more likely to have high rates of partner change and engage in a pattern of transactional sex than married women. Widowers took partners who were a median of 10 years younger than themselves. Mathematical model simulations of different scenarios of sexual behaviour of widows suggested that the sexual activity of widow(er)s may underlie 8-17% of new HIV infections over a 20-year period. This combined statistical analysis and model simulation suggest that widowhood plays an important role in the transmission of HIV in this rural Zimbabwean population. High-risk partnerships may be formed when widowed men and women reconnect to the sexual network.

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Editors’ note : The practice of widows marrying the brother of their deceased spouse, known as the ‘levirate’, appears to have declined in Zimbabwe, along with traditional practices discouraging widows from taking another partner for one year after the death of their spouse. Widows’ rights to inheritance are better protected, although less so for those married under customary law. Nevertheless, this modelling study in a rural area suggests that widows and widowers in this high prevalence setting are more likely to enter into high risk partnerships when they reconnect to the sexual network. Many of them likely need support and knowledge to make safe sexual choices after the death of a spouse. Widows in particular need legal advice and increased financial independence through employment opportunities to reduce their need for economic support from a new partner.

Reza A, Breiding MJ, Gulaid J, Mercy JA, Blanton C, Mthethwa Z, Bamrah S, Dahlberg LL, Anderson M. Sexual violence and its health consequences for female children in Swaziland: a cluster survey study. Lancet. 2009 Jun;373(9679):1966-72. 

Despite concern, few studies have been done about sexual violence against girls younger than 18 years of age in sub-Saharan Africa. Reza and colleagues report the prevalence and circumstances of sexual violence in girls in Swaziland, and assess the negative health consequences. They obtained data from a nationally representative sample of girls and women aged 13-24 years from selected households in Swaziland between May 15, 2007, and June 16, 2007, with a two-stage cluster design. The questionnaire examined demographics, type of sexual violence that took place before the respondent was 18 years of age, circumstances of the incident, and health-related conditions. Information was gathered from 1244 women and girls (response rate 96.3%), of whom 1242 provided retrospective responses to questions about sexual violence. The authors used regression models adjusted for relevant demographics to estimate the odds ratios for the associations between sexual violence and health-related conditions. Overall, 33.2% (95% CI 29.9-36.7) of respondents reported an incident of sexual violence before they reached 18 years of age. The most common perpetrators of the first incident were men or boys from the respondent’s neighbourhood (32.3% [28.8-36.1]) and boyfriends or husbands (26.2% [22.2-30.7]). The first incident most often took place in the respondent’s own home (26.1% [21.6-31.2]). Sexual violence was associated with reported lifetime experience of sexually transmitted diseases (adjusted OR 3.69 [95% CI 1.78-7.66]), pregnancy complications or miscarriages (3.54 [1.47-8.55]), unwanted pregnancy (2.92 [1.87-4.55]), and self-report of feeling depressed (2.30 [1.70-3.11]). Knowledge of the high prevalence of sexual violence against girls in Swaziland and its associated serious health-related conditions and behaviours should be used to develop effective prevention strategies.

Editors’ note: Sexual violence occurring before age 18 years, defined as forced intercourse, coerced intercourse, attempted unwanted intercourse, unwanted touching of the respondent, or forced touching of the perpetrator, was reported by over a third of the girls and women in this nationally representative UNICEF/CDC study in Swaziland. Programmes to prevent childhood sexual abuse and minimise its devastating short-term and long-term mental, reproductive, and physical health consequences need to engage communities beyond the health sector. Increasing the safety of the school environment and travel to and from schools are first steps, but unless perpetrators are subject to social and legal sanctions, sexual abuse of girls will occur and be repeated. Since both sexual violence and intimate partner violence may have common roots and links to HIV risk, all communities, particularly those with high HIV prevalence, need to be mobilised with support from local and national leaders to confront these human rights abuses.

Leclerc-Madlala S. Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability. AIDS. 2008;22 Suppl 4:S17-25.

Leclerc-Madlala reviews the current state of knowledge on age-disparate sexual relationships in the context of the southern African HIV hyperepidemic. Disproportionately high HIV infection rates among young women aged 15-24 years have been attributed to their greater involvement in relationships with older-aged partners. Whereas early studies emphasized economic concerns in the context of poverty as driving girls to accept or seek the attentions of older employed men, close-grained studies reveal a complex interplay of meanings and motives that prompt both men and women across socioeconomic strata to engage in intergenerational sex. Studies have revealed that age-disparate relationships are meaningful and perceived as beneficial at a number of levels, including social, physical, psychological, as well as economic and symbolic. In the context of growing economic inequalities and cultural expectations for men to give and women to receive a compensation for sex, relationships with older men are a common and readily available way through which young women gain materially, affirm self-worth, achieve social goals, increase longer-term life chances, or otherwise add value and enjoyment to life. Awareness of HIV risks in these relationships remains low. HIV prevention policies and programmes need to start from an understanding of how those engaged in risky behaviour perceive their sexual relationships and conceptualize the choices they make and the strategies they use. A more comprehensive policy on women and girls with better integration of communities in assessing and addressing issues, and an expansion of campaigns and programmes on the role of men as protectors and supporters of women are recommended.

Editors’ note: This excellent review describes the facilitating social factors in both rural and urban settings that may motivate younger women to value age-disparate sexual relationships for their potential to provide access to social, emotional, symbolic, and financial capital. While young women often hold positive perceptions toward age-disparate relationships, they are aware of the dangers of dependency and unsafe sex leading to pregnancy and sexually transmitted infections including HIV. Although they may be pushed into sexual liaisons with older men for survival reasons, many young women do not perceive themselves as victims. Acknowledging the implicit transactional and reciprocal elements of age-disparate sex and the wider realities of women’s lives in southern Africa is fundamental to a two-pronged approach that focuses on empowering women while working to change men’s behaviours and attitudes. In communities most at risk, creative ways need to be found to support male champions for HIV prevention who represent a masculinity that protects self and others from HIV. This article appeared in a journal supplement of papers drawn from a UNAIDS-convened consultation on the vulnerability of young women in southern Africa. The entire supplement can be downloaded free of charge, if you are among the first 5000 people interested, at https://articleworks.cadmus.com/doc/926318.

Intimate partner violence, defined as actual or threatened physical, sexual, psychological, and emotional abuse by current or former partners is a global public health concern. The prevalence and determinants of intimate partner violence against pregnant women has not been described in Rwanda. A study was conducted to identify variables associated with intimate partner violence among Rwandan pregnant women. A convenient sample of 600 pregnant women attending antenatal clinics were administered a questionnaire which included items on demographics, HIV status, intimate partner violence, and alcohol use by the male partner. Mean age and proportions of intimate partner violence in different groups were assessed. Odds of intimate partner violence were estimated using logistic regression analysis. Of the 600 respondents, 35.1% reported intimate partner violence in the last 12 months. HIV-positive pregnant women had higher rates of all forms of intimate partner violence than HIV-negative pregnant women: pulling hair (44.3% vs. 20.3%), slapping (32.0% vs. 15.3%), kicking with fists (36.3% vs. 19.7%), throwing to the ground and kicking with feet (23.3% vs. 12.7%), and burning with hot liquid (4.1% vs. 3.5%). HIV-positive participants were more than twice likely to report physical intimate partner violence than those who were HIV-negative (OR = 2.38; 95% CI [1.59, 3.57]). Other factors positively associated with physical intimate partner violence included sexual abuse before the age of 14 years (OR = 2.69; 95% CI [1.69, 4.29]), having an alcohol drinking male partner (OR = 4.10; 95% CI [2.48, 6.77] for occasional drinkers and OR = 3.37; 95% CI [2.05, 5.54] for heavy drinkers), and having a male partner with other sexual partners (OR = 1.53; 95% CI [1.15, 2.20]. Education was negatively associated with lifetime intimate partner violence. In reporting on prevalence of intimate partner violence among pregnant women attending antenatal care in Rwanda, Central Africa, the authors advocate that screening for intimate partner violence be an integral part of HIV care, as well as routine antenatal care. Services for battered women should also be made available.

Editors’ note: Intimate partner violence affects 25-43% of women globally at some point in their lifetime. That over one-third of pregnant women and almost one-half of HIV-positive pregnant women in this Rwandan study had experienced such violence in the past 12 months is striking. In addition to the significant mental and physical health consequences for women, physical violence increases the risk of low birth weight infants, pre-term delivery and neonatal death, and negatively affects breast feeding post partum. Prenatal care providers should have a high degree of suspicion of intimate partner violence among pregnant women with HIV infection and make a concerted effort to provide necessary social, treatment, and legal support for these women.

Conde DM, Silva ET, Amaral WN, Finotti MF, Ferreira RG, Costa-Paiva L, Pinto-Neto AM. HIV, reproductive aging, and health implications in women: a literature review. Menopause 2009; 16(1) [Epub ahead of print]

Infection by the human immunodeficiency virus (HIV) is increasing among women. After the advent of highly active antiretroviral therapy (HAART), a decrease occurred in the mortality rate, which now seems to have stabilized. One of the consequences of this current situation is that more and more HIV-infected women are now reaching menopause. Therefore, factors often investigated in seronegative women need to be evaluated in middle-aged, HIV-positive women. In midlife, HIV-positive women will experience the onset of menopause, while concomitantly they may also be affected by metabolic complications related to the HIV infection and to HAART. This literature review was therefore carried out to identify studies dealing with conditions related to middle-aged women with HIV with the aim of providing data on age at menopause, menopausal symptoms, reproductive hormones, cognitive function, bone mineral density, cardiovascular disease, and lipid and glucose metabolism in middle-aged women with HIV and discussing these issues. Some of these factors may be aggravated by the HIV infection and by HAART. The prevention and treatment of these conditions in middle-aged, HIV-positive women are discussed in the light of current knowledge.

Editors’ note: This excellent review from Brazil is timely because the number of middle-aged women living with HIV is increasing. This is in part the result of improved access to life-prolonging antiretroviral treatment and in part due to biological and social vulnerability to HIV acquisition during this phase of women’s lives. The review highlights the preventive and therapeutic measures needed to minimise the long-term complications of HIV and its treatment as the ovaries fail, as well as the importance of further studies to determine optimal therapies for the conditions experienced by middle-aged HIV-positive women.

Gupta J, Silverman JG, Hemenway D, Acevedo-Garcia D, Stein DJ, Williams DR. Physical violence against intimate partners and related exposures to violence among South African men. CMAJ. 2008;179(6):535-41.

Despite high rates of intimate partner violence in South Africa, there have been no national studies of men’s perpetration of violence against female partners. Gupta and colleagues analyzed data from the South Africa Stress and Health Study, a cross-sectional, nationally representative study, specifically examining data for men who had ever been married or had ever cohabited with a female partner. They calculated the prevalence of physical violence against intimate female partners and used logistic regression to examine associations with physical abuse during childhood and exposure to parental and community violence. A total of 834 male participants in the South Africa Stress and Health Study met the study criteria. Of these, 27.5% reported using physical violence against their current or most recent female partner during their current or most recent marriage or cohabiting relationship. Crude odds ratios (ORs) and 95% confidence intervals (CIs) indicated significant associations between perpetration of violence against an intimate partner and witnessing parental violence (OR 3.91, 95% CI 2.66-5.73) or experiencing physical abuse during childhood (OR 3.24, 95% CI 2.27-4.63), but not exposure to community violence (OR 1.29, 95% CI 0.88-1.88). The 2 significant associations persisted in adjusted analyses: OR 3.22 (95% CI 1.94-5.33) for witnessing parental violence and OR 1.73 (95% CI 1.07-2.79) for experiencing physical abuse during childhood. The authors concluded that they had found a high prevalence of physical violence perpetrated by men against their intimate partners. Men who experienced physical abuse during childhood or were exposed to parental violence were at the greatest risk.

Editors’ note: More than a quarter of men in this nationally representative study reported having perpetrated physical violence against their most recent partner. The estimate would likely have been higher if the question had been about lifetime perpetration of violence against all intimate partners. This behaviour was more prevalent in men who were abused themselves as children or who had witnessed parental violence. In both cases, this may have led them to view such behaviour as normative. Intimate partner violence, sexually risky behaviours, and HIV infection are interlinked making condemnation of intimate partner violence both an HIV prevention and human rights imperative.

Le Coeur S, Khlat M, Halembokaka G. Increased HIV infection rate among violent deaths: a mortuary study in the Republic of Congo. AIDS. 2008;22(13):1675-6.  

There is no evidence to suggest an association between violent deaths and HIV in Africa. Le Cœur and colleagues report the results of a study performed in Pointe-Noire, Congo, where post-mortem HIV serologies were performed among all deaths referred to the morgue. The HIV prevalence among violent deaths was 37%, significantly higher than 10% among accidental deaths, with an adjusted odds ratio of 6 (P = 0.03). Prevention of domestic violence and fight against stigmatization should be parts of HIV programmes in Africa.

Editors’ note: To obtain a death certificate for burial in Pointe-Noire, the bodies of all deceased persons must be taken to the city morgue, making for a relatively complete denominator. Of the 1309 deaths registered during the study period, 14 were homicides and 5 suicides. More than a third of these people were HIV-positive at the time of death. Of the 4 HIV-positive homicides, 3 were women who had been slaughtered by a family member. These small but striking numbers highlight the importance of fighting stigma and preventing domestic violence .

Denny L, Boa R, Williamson AL, Allan B, Hardie D, Stan R, Myer L. Human Papillomavirus Infection and Cervical Disease in Human Immunodeficiency Virus-1-Infected Women. Obstet Gynecol. 2008 Jun;111(6):1380-1387.

Denny et al report on the natural history of high-risk human papillomavirus (HPV) infection and cervical disease in human immunodeficiency virus (HIV)-1-infected women living in Cape Town, South Africa. They studied prospectively 400 untreated, HIV-1-infected women who underwent high-risk HPV DNA testing, cytology, colposcopy, histology, and CD4 count testing every 6 months for 36 months. Human immunodeficiency virus viral loads and HPV type distribution were determined at entry and after 18 months. Sixty-eight percent of the women were high-risk HPV DNA positive at entry, 35% had a cytologic diagnosis of low-grade squamous intraepithelial lesion (LSIL), and 13% had high-grade squamous intraepithelial lesion (HSIL). There were no cancers. Abnormal cytology and high-risk HPV positivity were strongly correlated with low CD4 counts and high HIV viral loads. The most prevalent types of HPV were HPV-16, -52, -53, -35, and -18. Incident high-risk HPV infection occurred in 22%, and of those infected with high-risk HPV, 94% of infections persisted over an 18-month period, and 6% cleared their infections. Cytologic progression to SIL from normal/atypical squamous cells of undetermined significance cytology occurred in 17% of cases, but only 4% of cases of LSIL progressed to HSIL. Denny et al concluded that there is a high level of high-risk HPV infection in HIV-1 infected women, but progression to HSIL over 36 months occurred in the minority of cases. They recommend an initial coloscopy for an abnormal test, and if no high-grade lesion is identified, triennial screening would be appropriate. Human papillomavirus type 16 was the commonest, and HPV-18 was the fifth commonest, suggesting that vaccination against these two types would have a significant effect. LEVEL OF EVIDENCE: II.

Editors’ note: These findings of high-risk HPV infection in more than two-thirds of 400 women living with HIV and abnormal cervical cytology in 55% of them at baseline in this 3 year study are concerning. The study found that HPV-associated disease was strongly influenced by immune status, as reflected in CD4 counts and viral loads, suggesting that antiretroviral treatment can play an important role in preventing progression to cervical cancer.

Jarrin I, Geskus R, Bhaskaran K, Prins M, Perez-Hoyos S, Muga R, Hernández-Aguado I, Meyer L, Porter K, del Amo J; CASCADE Collaboration. Gender differences in HIV progression to AIDS and death in industrialized countries: slower disease progression following HIV seroconversion in women. Am J Epidemiol. 2008 Sep 1;168(5):532-40. Epub 2008 Jul 28.

To evaluate sex differences in human immunodeficiency virus (HIV) disease progression before (pre-1997) and after (1997-2006) introduction of highly active antiretroviral therapy, the authors used data from a collaboration of 23 HIV seroconverter cohort studies from Europe, Australia, and Canada restricted to the 6,923 seroconverters infected through injecting drug use and sex between men and women. Within a competing risk framework, they used Cox proportional hazards models allowing for late entry to evaluate sex differences in time from HIV seroconversion to death, to acquired immunodeficiency syndrome (AIDS), and to each first AIDS-defining disease and death without AIDS. While no significant sex differences were found before 1997, from 1997 onward, women had a lower risk of AIDS (adjusted cumulative relative risk (aCRR) = 0.76, 95% confidence interval (CI): 0.63, 0.90) and death (adjusted hazard ratio = 0.68, 95% CI: 0.56, 0.82) than men did. Compared with men, women also had lower risks of AIDS dementia complex (aCRR = 0.23, 95% CI: 0.07, 0.74), tuberculosis (aCRR = 0.60, 95% CI:0.39, 0.92), Kaposi’s sarcoma (aCRR = 0.27, 95% CI: 0.07, 0.99), lymphomas (aCRR = 0.47, 95% CI: 0.23, 0.96), and death without AIDS (aCRR = 0.74, 95% CI: 0.56, 0.98). Sex differences in HIV disease progression have become larger and statistically significant in the era of highly active antiretroviral therapy, supporting a stronger impact of health interventions among women.

Editors’ note: This is the first study to examine sex differences in male and female seroconverters in the same transmission category. From 1997 onward, women had a lower mortality than men for both all-cause mortality and death without AIDS. These findings confirm those from European settings but not studies in the United States that have shown higher accident or injury-related mortality in women with HIV than in men and no reductions in overall mortality for women with HIV after the advent of antiretroviral treatment. These discrepancies may be due to stark socioeconomic differences between study populations, inclusion or exclusion of gay men, and differences in health care systems between Europe and the United States.

Fawole OI. Economic Violence to Women and Girls: Is It Receiving the Necessary Attention? Trauma Violence Abuse. 2008;9(3):167-77

Most studies on gender-based violence (GBV) have focused on its physical, sexual, and psychological manifestations. This paper seeks to draw attention to the types of economic violence experienced by women, and describes its consequences on health and development. Economic violence experienced included limited access to funds and credit; controlling access to health care, employment, education, including agricultural resources; excluding from financial decision making; and discriminatory traditional laws on inheritance, property rights, and use of communal land. At work women experienced receiving unequal remuneration for work done equal in value to the men’s, were overworked and underpaid, and used for unpaid work outside the contractual agreement. Some experienced fraud and theft from some men, illegal confiscation of goods for sale, and unlawful closing down of worksites. At home, some were barred from working by partners, while other men totally abandoned family maintenance to the women. Unfortunately, economic violence results in deepening poverty and compromises educational attainment and developmental opportunities for women. It leads to physical violence, promotes sexual exploitation and the risk of contracting HIV infection, maternal morbidity and mortality, and trafficking of women and girls. Economic abuse may continue even after the woman has left the abusive relationship. There is need for further large-scale studies on economic violence to women. Multi-strategy interventions that promote equity between women and men, provide economic opportunities for women, inform them of their rights, reach out to men and change societal beliefs and attitudes that permit exploitative behaviour are urgently required.

Editors’ note: Fighting economic violence is in everyone’s best interest. Nothing less than societal transformation is required. Strategies include undertaking diplomatic and political actions, mounting boycotts, initiating lawsuits, raising public awareness, educating boys and girls that economic violence is unacceptable, attracting media attention, enacting laws that prohibit economic violence against women, and monitoring national plans of action on equality for women. Economic violence increases the risk of HIV acquisition and transmission. Economic violence is predictable and, with political commitment and societal change, it is preventable.

Despite sensitising and prevention messages, women still remain concerned about HIV in developing countries. How do they perceive the illness and methods of prevention? The objective of this study was to assess the social diagnosis of HIV infection and AIDS illness, and endogenous strategies developed by women from Gaoua. A qualitative approach was adopted, involving four focus group discussions with women from the Lobi, Birifor, Dioula and Dagara ethnic groups. An interview guide was developed for the discussions, which were carried out in local languages, tape recorded, transcribed verbatim and analysed in detail. Specific descriptions of signs/symptoms of HIV infection and HIV-related illness were given. These were: Kpéré tchi (lose weight and die) gbè yirè (twig feet) sii dan (end of life) gbè milè (thin feet), respectively for Lobi, Birifor, Dioula and Dagara. The major signs of AIDS mentioned were weight loss, appetite for meat, good meals, curly hair, large spots on the body, high fever, diarrhoea, and redness of lips. In relation to these signs, some endogenous strategies were developed by women to protect themselves against the illness, including « observation » and hot spiced meals for a few days for a partner who was absent for a long time, as well as early marriage for young girls. The social diagnosis of HIV infection and AIDS illness by a specific group like women demonstrates the gap between perceptions of the illness and prevention messages. This could help to understand that it is important to take account of communities’ perceptions of illness in elaboration of prevention messages.

Editors’ note: In this culture, signs of immune system compromise such as wasting, Kaposi sarcoma, and oral candidiasis may be correctly perceived as indicating possible HIV infection, but curly hair and enjoying good meals, particularly those with meat, may lead women to falsely believe you are living with HIV. Unable to propose condom use, pejoratively called a ‘penis sack’, when their husbands return from voyages these married women rely on a home-grown HIV prevention technique of avoiding sex while feeding their husbands highly spiced food for several days to see if it provokes diarrhoea. The first strategy likely will not work for long and the second may produce lots of false positive results. Community HIV prevention conversations have to start with beliefs and involve men if they are to lead to exploration of real options for change.

Ba O, O’Regan C, Nachega J, Cooper C, Anema A, Rachlis B, Mills EJ. HIV/AIDS in African militaries: an ecological analysis. Med Confl Surviv. 2008;24(2):88-100.

The HIV pandemic is considered a security threat. Policy-makers have warned of destabilization of militaries due to massive troop deaths. Estimates of the rate of HIV within African militaries have been as high as 90 per cent. Ba and colleagues aimed to determine if HIV prevalence within African militaries is higher than their host nation prevalence rates. Using systematic searching and access to United States Department of Defense data, the authors abstracted data on prevalence within militaries and their host communities. They conducted a random effects pooled analysis to determine differences in HIV prevalence rates in the military versus the host population, obtaining data on 21 African militaries. In general, HIV prevalence within the military was elevated compared to the general population. The differences were significant (odds ratio 1.97, 95% confidence interval: 1.58-2.45, P < 0.001). Further, inflated rates of HIV in militaries compared to non-military males of similar age were also significant (6.09, 4.47-8.30, P < or = 0.0001). States with recent conflicts and wars had elevated military rates, but these were also not significant (P = 0.4). Population levels predicted military prevalence rates (P < or = 0.001). HIV prevalence rates in most African militaries are significantly elevated compared to their host communities.

Editors’ note: The high HIV prevalence documented in the militaries of some countries in Africa is not surprising given that they are comprised predominantly of young, sexually active males. It does raise concerns about the potential for shortages in the numbers of qualified and experienced military personnel available for deployment, particularly when the armed forces play a key role in maintaining and promoting peace in the region. Intensified HIV prevention and antiretroviral treatment are key to maintaining a healthy military.

HIV prevalence is rising, especially among high risk females in Tijuana, Baja California, a Mexico-US border city situated on major migration and drug trafficking routes. Strathdee and colleagues compared factors associated with HIV infection among male and female injection drug users in Tijuana in an effort to inform HIV prevention and treatment programmes. Injection drug users aged > or = 18 years were recruited using respondent-driven sampling and underwent testing for HIV, syphilis and structured interviews. Logistic regression identified correlates of HIV infection, stratified by gender. Among 1056 injection drug users, most were Mexican-born but 67% were born outside Tijuana. Reasons for moving to Tijuana included deportation from the US (56% for males, 29% for females), and looking for work/better life (34% for females, 15% for males). HIV prevalence was higher in females versus males (10.2% vs. 3.5%, p = 0.001). Among females (N=158), factors independently associated with higher HIV prevalence included younger age, lifetime syphilis infection and living in Tijuana for longer durations. Among males (N=898), factors independently associated with higher HIV prevalence were syphilis titres consistent with active infection, being arrested for having ‘track-marks’, having larger numbers of recent injection partners and living in Tijuana for shorter durations. An interaction between gender and number of years lived in Tijuana regressed on HIV infection was significant (p = 0.03). Upon further analysis, deportation from the U.S. explained the association between shorter duration lived in Tijuana and HIV infection among males; odds of HIV infection were four-fold higher among male injectors deported from the US, compared to other males, adjusting for all other significant correlates (p = 0.002). Geographic mobility has a profound influence on Tijuana’s evolving HIV epidemic, and its impact is significantly modified by gender. Future studies are needed to elucidate the context of mobility and HIV acquisition in this region, and whether US immigration policies adversely affect HIV risk.

Editors’ note: These findings suggest that geographic mobility may have had a differential effect on the risk of HIV infection among male and female injecting drug users in Tijuana, with a three-fold higher HIV prevalence documented among the women. However, its cross-sectional design means that a causal relationship cannot be confirmed. Nonetheless, supportive programmes for migrants, deportees, and other displaced persons on both sides of the U.S.-Mexico border could help mitigate the effects of social disruption and displacement.

Varga C, Brookes H. Factors Influencing Teen Mothers’ Enrolment and Participation in Prevention of Mother-to-Child HIV Transmission Services in Limpopo Province, South Africa. Qual Health Res. 2008;18(6):786-802.

In this article, Varga and colleagues examine barriers to HIV testing uptake and participation in prevention of mother-to-child HIV transmission services among adolescent mothers aged 15 to 19 years in rural and urban Limpopo Province, South Africa. The authors used the narrative research method involving key informants constructing typical case studies of adolescent experiences with HIV testing and entry into prevention of mother-to-child HIV transmission. Case studies formed the basis of a community-based questionnaire and focus group discussions with adolescent mothers. Client-counsellor dynamics during pre-test counselling were pivotal in determining uptake and participation, and counsellor profile strongly influenced the nature of the interaction. Other factors found to influence adherence to prevention of mother-to-child HIV transmission recommendations included HIV and early premarital pregnancy stigma, fear of a positive test result, and concerns over confidentiality and poor treatment by health care providers. Adolescents described elaborate strategies to avoid HIV disclosure to labour and delivery staff, despite knowing this would mean no antiretroviral therapy for their newborn infants. Theoretical, methodological, and programmatic implications of study findings are also discussed.

Editors’ note: By age 19, 30% of South African adolescent girls have been pregnant. Surveillance data estimate that more than 15% of pregnant adolescents are HIV-positive. The double stigma of pregnancy and HIV infection along with negative attitudes among health care workers poorly prepared to deal with adolescents underpin poor programme uptake. Sufficient training and adequate time to ensure supportive interactions during the initial pre-test counselling contact is an obvious first step to healthier outcomes for both adolescent mothers and their infants.

In developing countries, mother-to-child transmission of HIV is responsible for 5-10% of all new HIV infections. HIV positive mothers can transmit HIV to their babies during pregnancy, childbirth and breast-feeding. Anti-retroviral drugs are effective in reducing the risk of mother-to-child transmission of HIV. The main focus of this study was to describe mothers’ attitudes towards using services for preventing mother-to-child transmission of HIV. A non-experimental, descriptive design with a survey approach was used. The study was conducted at one hospital in Bulawayo, Zimbabwe that offers both prenatal clinic and maternity, including prevention of mother-to-child transmission, services. Fifty pregnant women, who attended prenatal clinics in Bulawayo and who booked to deliver their babies in the hospital’s maternity section, were interviewed. A structured interview survey was used to collect data. The interviewed women required more knowledge about preventing mother-to-child transmission of HIV. Many pregnant women would not use the services available for the prevention of mother-to-child transmission of HIV, for personal, financial and cultural reasons. However, the most important barriers preventing pregnant women from using free prevention of mother-to-child transmission services were structural ones. Only pregnant women who attended prenatal clinics and delivered their babies in hospital could access these services. Prenatal and delivery services might be beyond the financial reach of many Zimbabwean women, making prevention of mother-to-child transmission services inaccessible to them. Free infant formula could not be accessed at hospitals and clinics because of transport costs.

Editors’ note: This small study in one site highlights practical constraints that must be overcome to achieve universal access to prevention of mother-to-child transmission. Although HIV testing and counselling, antiretroviral prophylaxis, and counselling and support for safe infant feeding were available free of charge, basic pre-natal, delivery, and post-natal services were not. When women cannot access these because of transport or financial constraints, prevention of mother-to-child transmission doesn’t even make it to the table.

Bollen and colleagues aimed to evaluate the association between maternal herpes simplex virus type 2 seropositivity and genital herpes simplex virus type 2 shedding with perinatal HIV transmission. Women who participated in a 1996-1997 perinatal HIV transmission prevention trial in Thailand were evaluated. In this non-breastfeeding population, women were randomized to zidovudine or placebo from 36 weeks gestation through delivery; maternal plasma and cervicovaginal HIV viral load and infant HIV status were determined for the original study. Stored maternal plasma and cervicovaginal samples were tested for herpes simplex virus type 2 antibodies by enzyme-linked immunoassay and for herpes simplex virus type 2 DNA by real-time PCR, respectively. Among 307 HIV-positive women with available samples, 228 (74.3%) were herpes simplex virus type 2 seropositive and 24 (7.8%) were shedding herpes simplex virus type 2. Herpes simplex virus type 2 seropositivity was associated with overall perinatal HIV transmission [adjusted odds ratio, 2.6; 95% confidence interval, 1.0-6.7)], and herpes simplex virus type 2 shedding was associated with intrapartum transmission (adjusted odds ratio, 2.9; 95% confidence interval, 1.0-8.5) independent of plasma and cervicovaginal HIV viral load, and zidovudine treatment. Median plasma HIV viral load was higher among herpes simplex virus type 2 shedders (4.2 vs. 4.1 log(10)copies/ml; P = 0.05), and more shedders had quantifiable levels of HIV in cervicovaginal samples, compared with women not shedding herpes simplex virus type 2 (62.5 vs. 34.3%; P = 0.005). The authors found an increased risk of perinatal HIV transmission among herpes simplex virus type 2 seropositive women and an increased risk of intrapartum HIV transmission among women shedding herpes simplex virus type 2. These novel findings suggest that interventions to control herpes simplex virus type 2 infection could further reduce perinatal HIV transmission.

Editors’ note: Co-infected women had higher HIV plasma viral loads than did women without herpes simplex virus-2 (HSV-2) in this study which may explain why women with HSV-2 were more likely to transmit to their infants. If these findings are replicated among women receiving currently recommended drugs for prophylaxis of mother-to-child transmission, further evaluation is warranted of adding suppressive treatment for HSV-2 to help prevent mother-to-child transmission. Acyclovir, a drug that is well tolerated in pregnancy, is off patent and cheap.

Kigozi G, Gray RH, Wawer MJ, Serwadda D, Makumbi F, Watya S, Nalugoda F, Kiwanuka N, Moulton LH, Chen MZ, Sewankambo NK, Wabwire-Mangen F, Bacon MC, Ridzon R, Opendi P, Sempijja V, Settuba A, Buwembo D, Kiggundu V, Anyokorit M, Nkale J, Kighoma N, Charvat B. The Safety of Adult Male Circumcision in HIV-Infected and Uninfected Men in Rakai, Uganda. PLoS Med. 2008;5(6):e116.

The objective of the study was to compare rates of adverse events related to male circumcision in HIV-positive and HIV-negative men in order to provide guidance for male circumcision programmes that may provide services to HIV-infected and uninfected men. A total of 2,326 HIV-negative and 420 HIV-positive men (World Health Organization stage I or II and CD4 counts > 350 cells/mm(3)) were circumcised in two separate but procedurally identical trials of male circumcision for HIV and/or sexually transmitted infection prevention in rural Rakai, Uganda. Participants were followed at 1-2 days and 5-9 days, and at 4-6 weeks, to assess surgery-related adverse events, wound healing, and resumption of intercourse. Adverse event risks and wound healing were compared in HIV-positive and HIV-negative men. Adjusted odds ratios were estimated by multiple logistic regression, adjusting for baseline characteristics and postoperative resumption of sex. At enrolment, HIV-positive men were older, more likely to be married, reported more sexual partners, less condom use, and higher rates of sexually transmitted disease symptoms than HIV-negative men. Risks of moderate or severe adverse events were 3.1/100 and 3.5/100 in HIV-positive and HIV-negative participants, respectively (Adjusted odds ratio 0.91, 95% confidence interval [CI] 0.47-1.74). Infections were the most common adverse events (2.6/100 in HIV-positive versus 3.0/100 in HIV-negative men). Risks of other complications were similar in the two groups. The proportion with completed healing by 6 weeks post surgery was 92.7% in HIV-positive men and 95.8% in HIV-negative men (p = 0.007). Adverse events were more common in men who resumed intercourse before wound healing compared to those who waited (Adjusted odds ratio 1.56, 95% CI 1.05-2.33). In conclusion, the overall safety of male circumcision was comparable in asymptomatic HIV-positive and HIV-negative men, although healing was somewhat slower among the HIV infected. All men should be strongly counselled to refrain from intercourse until full wound healing is achieved. Trial registration: http://www.ClinicalTrials.gov; for HIV-negative men, and for HIV-positive men.

Editors’ note: The finding that there is no difference in the risk of adverse events for asymptomatic HIV-positive and HIV-negative men is encouraging because HIV testing is not mandatory for circumcision. HIV testing is a key voluntary component of a comprehensive service but all men who are in good health may undergo circumcision whether they decide to be tested or not. They should all be advised that early resumption of sexual intercourse has been shown to delay wound healing. As well, preliminary data from other studies and common sense concur that sex before complete wound healing may increase their risk of acquiring HIV, rather than protecting them, and may increase their risk of transmitting HIV to a sexual partner if they already have HIV infection.

With the growing incidence of HIV, there is a desperate need to develop simple, cheap, and effective new ways of preventing HIV infection. Male circumcision reduces the risk of infection by about 60%, probably because of the removal of the Langerhans cells which are abundant in the inner foreskin and are the primary route by which HIV enters the penis. Langerhans cells form a vital part of the body’s natural defence against HIV and only cause infection when they are exposed to high levels of HIV virions. Rather than removing this natural defence mechanism by circumcision, it may be better to enhance it by thickening the layer of keratin overlying the Langerhans cells, thereby reducing the viral load to which they are exposed. Pask and colleagues investigated the ability of topically administered oestrogen to induce keratinization of the epithelium of the inner foreskin. Histochemically, the whole of the foreskin is richly supplied with oestrogen receptors. The epithelium of the inner foreskin, like the vagina, responds within 24 hours to the topical administration of oestriol by keratinization, and the response persists for at least 5 days after the cessation of the treatment. Oestriol, a cheap, readily available natural oestrogen metabolite, rapidly keratinizes the inner foreskin, the site of HIV entry into the penis. This thickening of the overlying protective layer of keratin should reduce the exposure of the underlying Langerhans cells to HIV virions. This simple treatment could become an adjunct or alternative to surgical circumcision for reducing the incidence of HIV infection in men

Editors’ note: Langerhans cells are no more abundant in the inner foreskin than they are in the outer foreskin or shaft of the penis, but the thinner protective keratin layer of the inner foreskin makes them more accessible for HIV. The abstract does not describe the methodology. Two sexually inactive uncircumcised men applied oestrogen cream to the inner foreskin daily for 14 days before undergoing circumcision. Contact smears taken daily and surgical tissue sections were examined. Keratinisation increased for these two men but this does not translate into protection against HIV. Clinical trials to evaluate efficacy would be required before conclusions could be drawn about whether oestrogen cream plays any role in HIV prevention for insertive men.

Sebert Kuhlmann AK, Kraft JM, Galavotti C, Creek TL, Mooki M, Ntumy R. Radio role models for the prevention of mother-to-child transmission of HIV and HIV testing among pregnant women in Botswana. Health Promot Int. 2008 Apr 11 [Epub ahead of print]

Although Botswana supports a program for the prevention of mother-to-child-transmission of HIV (PMTCT), many women initially did not take advantage of the program. Using data from a 2003 survey of 504 pregnant and post-partum women, Sebert Kuhlmann and his colleagues assessed associations between exposure to a long-running radio serial drama that encourages use of the PMTCT program and HIV testing during pregnancy. Controlling for demographic, pregnancy and other variables, women who spontaneously named a PMTCT character in the serial drama as their favourite character were nearly twice as likely to test for HIV during pregnancy as those who did not. Additionally, multiparity, knowing a pregnant woman taking AZT, having a partner who tested, higher education and PMTCT knowledge were associated with HIV testing during pregnancy. Identification with characters in the radio serial drama is associated with testing during pregnancy. Coupled with other supporting elements, serial dramas could contribute to HIV prevention, treatment and care initiatives.

Editors’ note: This programme went further than public service announcements and counselling sessions to raise awareness of PMTCT services. It used two fundamental principles: modelling (showing people how to change) and reinforcement (supporting their efforts to change and to maintain healthy behaviours). The radio drama was the modelling component and may have helped some women to see HIV testing in pregnancy as a good choice supported by social norms. It is interesting to speculate whether this programme paved the way for broad acceptance of the introduction of a routine offer of antenatal testing in 2004.

Wringe A, Isingo R, Urassa M, Maiseli G, Manyalla R, Changalucha J, Mngara J, Kalluvya S, Zaba B. Uptake of HIV voluntary counselling and testing services in rural Tanzania: implications for effective HIV prevention and equitable access to treatment. Trop Med Int Health. 2008;13(3):319-27.

Wringe and colleagues aimed to describe the associations between socio-demographic, behavioural and clinical characteristics and the use of HIV voluntary counselling and testing (VCT) services among residents in a rural ward in Tanzania. Eight thousand nine hundred and seventy participants from a community-based cohort were interviewed, provided blood for research HIV testing, and were offered VCT. Univariate and multivariate logistic regression was used to identify socio-demographic, clinical, and behavioural factors associated with VCT use. Although 31% (1246/3980) of men and 24% (1195/4990) of women expressed an interest in the service, only 12% of men and 7% of women subsequently completed VCT. Socio-demographic factors, such as marital status, area of residence, religion and ethnicity influenced VCT completion among males and females in different ways, while self-perceived risk of HIV, prior knowledge of VCT, and sex with a high-risk partner emerged as important predictors of VCT completion among both sexes. Among males only, those infected with HIV for 5 years or less tended to self-select for VCT compared to HIV-negatives (adjusted odds ratio = 1.43; 95% CI: 0.99-2.14). This contributed to a higher proportion of HIV-positive males knowing their status compared to HIV-positive females.  In this setting, a disproportionate number of HIV-positive women are failing to learn their status, which has implications for equitable access to onward referral for care and treatment services. Evidence that some high-risk behaviours may prompt VCT use is encouraging, although further interventions are required to improve knowledge about HIV risk and the benefits of VCT. Targeted interventions are also needed to promote VCT uptake among married women and rural residents.

Editors´note: Both the proportion of people interested in learning their HIV serostatus and the proportion of people who actually got tested are very low for a country with a sizeable HIV epidemic. It is likely that fear of stigma and discrimination had remained an important barrier to HIV testing during this study, since the Tanzanian government had already announced on radio and in newspapers that it intended to start providing free antiretroviral treatment though major hospitals.

Watts DH, Park JG, Cohn SE, Yu S, Hitti J, Stek A, Clax PA, Muderspach L, Lertora JJ. Safety and tolerability of depot medroxyprogesterone acetate among HIV-infected women on antiretroviral therapy: ACTG A5093. Contraception. 2008;77(2):84-90. Epub 2007 Dec 21.

Concomitant use of antiretroviral drugs and hormonal contraceptives may change the metabolism of each and the resulting safety profiles. We evaluated the safety and tolerability of depot medroxyprogesterone acetate among women on antiretroviral drugs. HIV-infected women on selected antiretroviral drug regimens or no antiretroviral drugs were administered medroxyprogesterone acetate 150 mg intramuscularly and evaluated for 12 weeks for adverse events, changes in CD4+ count and HIV RNA levels, and ovulation. Seventy evaluable subjects were included, 16 on nucleoside only or no antiretroviral drugs, 21 on nelfinavir-containing regimens, 17 on efavirenz-containing regimens and 16 on nevirapine-containing regimens. Nine Grade 3 or 4 adverse events occurred in seven subjects; none were judged related to medroxyprogesterone acetate. The most common findings possibly related to medroxyprogesterone acetate were abnormal vaginal bleeding (nine, 12.7%), headache (three, 4.2%), abdominal pain, mood changes, insomnia, anorexia and fatigue, each occurring in two (2.9%) subjects. No significant changes in CD4+ count or HIV RNA levels occurred with DMPA. No evidence of ovulation was detected, and no pregnancies occurred. In conclusion, the clinical profile associated with medroxyprogesterone acetate administration in HIV-infected women, most on antiretroviral drugs, appears similar to that seen in HIV-uninfected women. medroxyprogesterone acetate prevented ovulation and did not affect CD4+ counts or HIV RNA levels. In concert with previously published medroxyprogesterone acetate/antiretroviral drugs interaction data, these data suggest that medroxyprogesterone acetate can be used safely by HIV-infected women on the antiretroviral drugs studied.

Editors´note: These results are reassuring, particularly for women on efavirenz, a drug with potential teratogenic effects. However, the number of study participants was small and this was a 12-week study. Long-term DMPA use is associated with increases in weight and fat distribution, which may be exacerbated by some antiretroviral drugs.