HIV This Week

Loutfy MR, Macdonald S, Myhr T, Husson H, Du Mont J, Balla S, Antoniou T, Rachlis A. Prospective cohort study of HIV post-exposure prophylaxis for sexual assault survivors. Antivir Ther. 2008;13(1):87-95

There is a lack of standardized programs for HIV counselling and post-exposure prophylaxis (PEP) in the setting of sexual assault. Loutfy and associates conducted an 18-month prospective cohort study assessing universal HIV counselling for all sexual assault survivors presenting to 18 Ontario Sexual Assault Treatment Centres. HIV PEP was universally offered to those at risk of HIV infection (high risk or unknown risk) presenting < or =72 h after the assault, using Combivir (Lamivudine/Zidovudine) one pill and Kaletra (Lopinavir/Ritonavir) three capsules twice a day for 28 days. Those who accepted HIV PEP were monitored via a schedule of frequent follow ups. The primary outcomes were acceptance and completion rates, and their predictors were determined using multivariable logistic regression. Adverse events were categorized using a standardized toxicity grading system. Of the 900 evaluable participants eligible for PEP, 798 (69 at high risk and 729 at unknown risk) were offered treatment. Acceptance rates were 66.7% (n=46) and 41.3% (n=301) for participants at high risk and unknown risk, respectively. Participants at high risk were 2.2 times more likely to accept PEP than those at unknown risk (adjusted odds ratio 2.2; 95% confidence interval 1.2-4.0; P=0.01). Overall, 23.9% high-risk (n=11) and 33.2% unknown-risk participants (n=100) completed PEP (P=0.20). Predictors of acceptance and completion included assault by a stranger and participant anxiety. Adverse events were common, with 77.1% of participants reporting grade 2-4 symptoms. A province-wide standardized program of universal HIV counselling and offering of PEP to sexual assault survivors with frequent follow up was successfully implemented and feasible.

Editors´note: Post-exposure prophylaxis for sexual assault survivors requires contact with the health system within 72 hours of the attack, availability of antiretroviral drugs and willingness to take them, and, in most cases, consent for HIV testing and counselling. Both anxiety and perceived risk that the assailant could have been HIV-positive influence uptake and completion, but so do side effects. Only 32% of those who started on post-exposure prophylaxis actually finished the 28-day course.

Gazi R, Mercer A, Wansom T, Kabir H, Saha NC, Azim T. An assessment of vulnerability to HIV infection of boatmen in Teknaf, Bangladesh. Confl Health. 2008;2(1):5

Mobile population groups are at high risk for contracting HIV infection. Many factors contribute to this risk, including high prevalence of risky behaviour and increased risk of violence due to conflict and war. The Naf River serves as the primary border crossing point between Teknaf, Bangladesh, and Mynamar [Burma] for both official and unofficial travel of people and goods. Little is known about the risk behaviour of boatmen who travel back and forth between Teknaf and Myanmar. However, Gazi and colleagues hypothesize that boatmen may act as a bridging population for HIV between the high-prevalence country of Myanmar and the low-prevalence country of Bangladesh. Methods included initial rapport building with community members, mapping of boatmen communities, and in-depth qualitative interviews with key informants and members from other vulnerable groups such as spouses of boatmen, female sex workers, and injecting drug users. Information from the first three stages was used to create a cross-sectional survey that was administered to 433 boatmen. Over 40% of the boatmen had visited Myanmar during the course of their work. 17% of these boatmen had sex with sex workers while abroad. There was a significant correlation found between the number of nights spent in Myanmar and sex with commercial sex workers. In the past year, 19% of all boatmen surveyed had sex with another man. Fourteen per cent of boatmen had participated in group sex, with groups ranging in size from three to fourteen people. Condom use was rare [0 to 4.7% during the last month], irrespective of types of sex partners. Regression analysis showed that boatmen who were 25 years and older were statistically less likely to have sexual intercourse with non- marital female partners in the last year compared to the boatmen aged less than 25 years. Similarly, deep sea fishing boatmen and non-fishing boatmen were statistically less likely to have sexual intercourse with non-marital female partners in the last year compared to the day-longfishing boatmen adjusting for all other variables. Boatmen’s knowledge regarding HIV transmission and personal risk perception for contracting HIV was low. Boatmen in Teknaf are an integral part of a high-risk sexual behaviour network between Myanmar and Bangladesh. They are at risk of obtaining HIV infection due to cross-border mobility and unsafe sexual practices. There is an urgent need for designing interventions targeting boatmen in Teknaf to combat an impending epidemic of HIV among this group. They could be included in the serological surveillance as a vulnerable group. Interventions need to address issues on both sides of the border, other vulnerable groups, and refugees. Strong political will and cross-border collaboration are mandatory for such interventions.

Hunter M. The changing political economy of sex in South Africa: the significance of unemployment and inequalities to the scale of the AIDS pandemic. Soc Sci Med. 2007;64(3):689-700.

Between 1990 and 2005, HIV prevalence rates in South Africa jumped from less than 1% to around 29%. Important scholarship has demonstrated how racialized structures entrenched by colonialism and apartheid set the scene for the rapid unfolding of the AIDS pandemic, like other causes of ill-health before it. Of particular relevance is the legacy of circular male-migration, an institution that for much of the 20th century helped to propel the transmission of sexually transmitted infections among black South Africans denied permanent urban residence. But while the deep-rooted antecedents of AIDS have been noted, less attention has been given to more recent changes in the political economy of sex, including those resulting from the post-apartheid government’s adoption of broadly neo-liberal policies. As an unintentional consequence, male migration and apartheid can be seen as almost inevitably resulting in AIDS, a view that can disconnect the pandemic from contemporary social and economic debates. Combining ethnographic, historical, and demographic approaches, and focusing on sexuality in the late apartheid and early post-apartheid periods, this article outlines three interlinked dynamics critical to understanding the scale of the AIDS pandemic: (1) rising unemployment and social inequalities that leave some groups, especially poor women, extremely vulnerable; (2) greatly reduced marital rates and the subsequent increase of one person households; and (3) rising levels of women’s migration, especially through circular movements between rural areas and informal settlements/urban areas. As a window into these changes, the article gives primary attention to the country’s burgeoning informal settlements–spaces in which HIV rates are reported to be twice the national average–and to connections between poverty and money/sex exchanges.

Editors´note: Political economy analyses help conceptualise HIV as a symptom of ‘structural violence’ with sex as a mode of transmission. Housing, employment, and social equality are clearly linked to HIV, both historically and contemporarily, and help explain the striking scale of the South African epidemic. This article, which suggests ways to reconfigure the response to AIDS around a more politically enabling agenda, makes for thought-provoking reading.

Kang M, Dunbar M, Laver S, Padian N. University of California Programme in Women’s Health, University of California-San Francisco, 50 Beale Street, San Francisco, CA 94105, USA. Maternal versus paternal orphans and HIV/STI risk among adolescent girls in Zimbabwe. AIDS Care. 2008;20(2):214-7.

The AIDS epidemic has contributed to a drastic increase in the number of orphans in Zimbabwe. Orphans (whether orphaned by AIDS or other causes) have been shown to have economic and educational disadvantages as well as poor reproductive health outcomes. Kang and colleagues recruited a convenience sample of 200 girls in a peri-urban area of Zimbabwe to examine the impact of orphan status (compared to non-orphans) on household composition, education, risk behaviour, pregnancy and prevalent HIV and HSV-2 infection. In the study population, maternal orphans were more likely to be in households headed by themselves or a sibling, to be sexually active, to have had a sexually transmitted infection, to have been pregnant and to be infected with HIV. Paternal orphans were more likely to have ever been homeless and to be out of school. The findings suggest that maternal care and support is important for HIV prevention. This finding corroborates previous research in Zimbabwe and has implications for intervention strategies among orphan girls.

Editors´note: Because of recruitment methodology, these results are not generalizable, however they do provide food for thought. Although paternal orphanhood had more of an impact on household financial stability and orphaned girls’ educational attainment, the loss of a mother affected behavioural risk and biological outcomes (HIV, HSV-2). Keeping mothers alive helps reduce sexual risk in adolescent girls. How would orphaned adolescent girls in Zimbabwe benefit from support and mentoring by women in their communities?

Hargrove, John. Migration, mines and mores: the HIV epidemic in southern Africa. South Afr J Sci. 2008: Volume 104, Issue 1 & 2:53-61.

The seriousness of the HIV epidemic in southern and eastern Africa has its roots in the 19th century - in the employment practices instituted on mines, farms and in cities, where millions of men have, ever since, lived apart from their families for the greater part of each year. This destruction of the family unit was a sociological disaster waiting for the arrival of HIV and is the source of many other social ills - not least the increasingly violent nature of South African society. In the short term we can promote HIV prevention measures such as male circumcision and condom use. In the medium term, we can hope that the many billions already spent on microbicide and vaccine research begin to pay dividends. In the long term, we need to change fundamentally the way that people live.

Editors’ note: Hargrove cogently argues that it is “Rhodes not roads”, i.e. that it was the colonial migratory labour practices that fragmented families and severely compromised family coherence that were the critical determinants at the heart of the southern Africa epidemic. His unavoidable conclusion is that, in addition to intensifying HIV prevention and treatment, we must urgently rebuild family structures in southern and eastern Africa if the HIV epidemic and many other problems having similar sociological determinants are to be dealt with effectively.

Hladik and colleagues amied to estimate the burden of HIV disease in Uganda and the effect of HIV control programmes to mitigate it. The authors performed mathematical modelling and projecting using surveillance and census data. Using antenatal clinic surveillance (1986-2002) and a recent population-based survey (2004-2005) data, they modelled the adult national HIV prevalence over time (1981-2004), and kept prevalence constant at 6.4% for the years 2004-2010. Using Spectrum software and census data, they estimated the national burden of HIV disease and the effect of selected HIV-related prevention and treatment programmes. In 2005, they estimated that there were 135,300 new HIV infections (adult HIV incidence 0.96%), 691,900 asymptomatic prevalent infections, 88 100 AIDS cases, and 76 400 AIDS deaths. An estimated 647,000 (80%) HIV-infected adults were unaware of their infection; one third of all adult deaths were HIV related. As a result of population growth, by 2008 a similar number of people will be HIV infected (1.1 million) as during the peak of the epidemic in 1994. Although antiretroviral therapy coverage is expected to rise from 67,000 (2005) to 160,000 (2010), the number of persons needing but not receiving antiretroviral therapy will decrease only slightly from 127,600 (2005) to 111,100 (2010). The use of single-dose in 2005 nevirapine probably averted only 4% of the estimated 20 400 vertical infections. In conclusion, HIV continues to be a leading cause of adult disease and death in Uganda. Universal antiretroviral therapy access is probably unachievable. With the absolute burden of HIV disease approaching the historic peak in the early 1990s, more effective prevention programmes are of paramount importance.

Editors’ note: Although HIV prevalence has declined significantly since the mid-1990s in Uganda, a country with one of the oldest epidemics in the world, the burden of HIV remains high. An important majority of people living with HIV are unaware of their HIV status and therefore are not being evaluated for treatment initiation. New HIV infections that continue to outpace AIDS deaths mean that the total number of people living with HIV this year will reach the 1994 historic peak of 1.1 million people living with HIV, all of whom will eventually need treatment. This is no time for Uganda, and other countries reporting declines in HIV transmission in specific populations, to rest on its laurels. Continued treatment scale-up accompanied by intensified, evidence-informed prevention are urgently needed.

Sikkema KJ, Wilson PA, Hansen NB, Kochman A, Neufeld S, Ghebremichael MS, KershawT. Effects of a coping intervention on transmission risk behavior among people living with HIV/AIDS and a history of childhood sexual abuse. J Acquir Immune Defic Syndr. 2008; 47(4):506-13.

Sikkema and colleagues examine the effect of a 15-session coping group intervention compared with a 15-session therapeutic support group intervention among HIV-positive men and women with a history of childhood sexual abuse on sexual transmission risk behaviour. In a randomized controlled behavioural intervention trial with 12-month follow-up, a diverse sample of 247 HIV-positive men and women with histories of childhood sexual abuse was randomized to 1 of 2 time-matched group intervention conditions. Sexual behaviour was assessed at baseline; immediately after the intervention; and at 4-, 8-, and 12-month follow up periods (5 assessments). Changes in frequency of unprotected anal and vaginal intercourse by intervention condition were examined using generalized linear mixed models for all partners, and specifically for HIV-negative or serostatus unknown partners. Participants in the HIV and trauma coping intervention condition decreased their frequency of unprotected sexual intercourse more than participants in the support intervention condition for all partners (P < 0.001; d = 0.38, 0.32, and 0.38 at the 4-, 8-, and 12-month follow-up periods, respectively) and for HIV-negative and serostatus unknown partners (P < 0.001; d = 0.48, 0.39, and 0.04 at the 4-, 8-, and 12-month follow-up periods, respectively). The authors conclude that a group intervention to address coping with HIV and childhood sexual abuse can be effective in reducing transmission risk behaviour among HIV-positive men and women with histories of sexual trauma.

Editors’ note: From one-third to two-thirds of people living with HIV in the USA report a history of having been sexually abused as children, more than double the estimated rates in the general population. The association between childhood sexual abuse and sexual risk behaviours is well documented. The participants randomised to the coping group intervention benefited from adaptive coping skills building for confronting the combined stress and emotional consequences of child sexual abuse and HIV. Focusing on psychological adjustment and development of adaptive coping skills had a significantly greater effect on safer sex practices than a therapeutic support group and probably had similar unmeasured effects on coping in other areas of life.

Zungu-Dirwayi N, Shisana O, Louw J, Dana P. Social determinants for HIV prevalence among South African educators. AIDS Care. 2007; 19(10):1296-303.

HIV prevalence among women in South Africa continues to be high despite the availability of a comprehensive plan for the control of HIV and a plethora of prevention programmes. Any explanation for the ongoing high HIV prevalence continues to be elusive. The objective of this study was to understand the relationship between HIV, gender, race, and socioeconomic status among South African public sector educators in order to inform prevention programmes. A cross-sectional survey involving a probability sample of 1,766 schools out of 26,713 in the Department of Education Register of School Needs was selected. A sample of 24,200 respondents out of 356,749 public sector educators participated in the study. Nurses registered with the South African Nursing Council were recruited, trained to conduct interviews and to collect specimens for HIV testing. The study found an association between HIV, gender, race, and socioeconomic status among educators. African educators showed a higher HIV prevalence than other race groups. Among females, the highest HIV prevalence was among educators aged 25-35 years and in males aged 36-49 years. Further, educators with a high income and educational qualifications had a lower HIV prevalence compared to educators with low income and low educational qualifications, regardless of sex. Migration and marital factors were also found to play a role in HIV infection. The results suggest that HIV prevention needs to take into account critical issues around empowerment of vulnerable groups such as women and certain race groups to be able to implement safe sexual practices and therefore reduce HIV infections.

Editors’ note: Nearly 13% of all educators were HIV-positive in this study, a tremendous toll for any educational system. HIV prevalence in women who began teaching being married (14.7%) or engaged (11.4%) was lower than that among those who began their career being single (25.4%). Prevention programmes for young, single, female educators who are mobile are urgently needed. Educators of both sexes who were placed away from their families on completion of their studies had a significantly higher HIV prevalence. School boards need to consider the advantages of keeping teachers’ families with them to preserve mid-to-long term teaching capacity.

This study examined the role of hunger and food insecurity in the sexual behaviour of female sex workers in Lagos metropolis, Nigeria within the context of HIV. In addition, the study investigated the prevalence of sexually transmitted infections and induced abortion among the respondents. Cross-sectional survey and in-depth interview research methods were adopted to generate both quantitative and qualitative data from the respondents. The study showed that 35.0% of the respondents joined the sex industry because of poverty and lack of other means of getting daily food. While all the respondents had knowledge about the existence of HIV and AIDS, 82.0% of them identified sexual intercourse as a major route of HIV transmission. There was a significant relationship between poverty, food insecurity, and consistent use of condoms by female sex workers at P<0.01. Specifically, only 24.7% of the respondents used condoms regularly in every sexual act. Consequently, 51.6% had previous cases of sexually transmitted infections. The most prevalent sexually transmitted infection among the respondents was gonorrhoea, with 76.4% prevalence among ever infected female sex workers. This was followed by syphilis with a prevalence of 21.1%. In addition, 59.1% of the sample had become pregnant while on the job and 93.1% of these pregnancies were aborted through induced abortion. In conclusion, hunger and malnutrition were the factors that pushed young women into prostitution in Nigeria and these same factors hindered them from practicing safe sex within the sex industry. Thus, it is recommended that the Nigerian government should develop programmes that will reduce hunger and food insecurity, in order to reduce rapid transmission of HIV infection in the country.

Editors’ note: The links between hunger, food insecurity, and vulnerability to HIV described by this article are brought into sharp relief by the current global food crisis. Improving local food production to meet basic food needs not only helps reduce poverty levels; it pulls the rug out from under food insecurity as a driver of the HIV epidemic.

Cáceres CF, Konda KA, Salazar X, Leon SR, Klausner JD, Lescano AG, Maiorana A, Kegeles S, Jones FR, Coates TJ; The NIMH HIV/STD Collaborative Intervention Trial. New Populations at High Risk of HIV/STIs in Low-income, Urban Coastal Peru. AIDS Behav. 2007 Dec 27 [Epub ahead of print]

The HIV epidemic in Peru is concentrated primarily among men who have sex with men. HIV interventions have focused exclusively on a narrowly defined group of men who have sex with men and female sex workers to the exclusion of other populations potentially at increased risk. Interventions targeting men who have sex with men and female sex workers are insufficient and there is evidence that focusing prevention efforts solely on these populations may ignore others that do not fall directly into these categories. Cáceres and colleagues describe non-traditional, vulnerable populations within low-income neighbourhoods. These populations were identified through the use of ethnographic and epidemiologic formative research methods and the results are reported in this publication. Although the traditional vulnerable groups are still in need of prevention efforts, this study provides evidence of previously unrecognized populations at increased risk that should also receive attention from HIV and other sexually transmitted diseases prevention programmes.

Editors’ note: Highlighting the importance of ‘know your epidemic’, this study found esquineros (“street corner men” with limited education, who are financially dependent on their families and tend to engage in petty crime) and movidas (“active women” who spend time, drink alcohol, and have sex with esquineros) have similar HIV and syphilis prevalence as the general population but markedly different sexual risk behaviours. Prevention programmes focused on the general population or on known populations at higher risk of HIV exposure will not reach these sub-populations which need context-appropriate services.

Tanaka Y, Kunii O, Hatano T, Wakai S. Knowledge, attitude, and practice (KAP) of HIV prevention and HIV infection risks among Congolese refugees in Tanzania. Health Place. 2007 Sep 21; [Epub ahead of print].

Little is known about HIV infection risks and risk behaviours of refugees living in resource-scarce post-emergency phase camps in Africa. This study at Nyarugusu Camp in Tanzania, covering systematically selected refugees (n=1140) and refugees living with HIV (PLHIV) (n=182), revealed that the level of HIV risk of systematically selected refugees increased after displacement, particularly regarding the number having transactional sex for money or gifts, while radio broadcast messages are perceived to promote a base of risk awareness within the refugee community. While condoms are yet to be widely used in the camp, some refugees having transactional sex tended to undertake their own health initiatives such as using a condom, under the influence of peer refugee health workers, particularly health information team members. Nevertheless, PLHIV were less faithful to one partner and had more non-regular sexual partners than the group without HIV. The study revealed that community-based outreach by refugee health workers is conducive to risk behaviour prevention in the post-emergency camp setting. It is recommended to increase the optimal use of « radio broadcast messages » and « health information team, » which can act as agents to reach out to wider populations, and to strengthen the focus on safer sex education for PLHIV; the aim being to achieve dual risk reduction for both refugees living with and without HIV.

Editors’ note: This study found that 18.8% of female refugees and 24.7% of male refugees were involved in transactional sex in the preceding 12 months. Fellow Congolese refugees represented the principal transactional sex partners for both males and females, with persons from local Tanzanian communities ranking second for men while police and humanitarian workers ranked second and third, respectively, in the case of women and adolescent girls 15 years of age and older. Condom use was low but significantly more likely in transactional sex, suggesting that the community outreach and peer education, which are having effect in this post emergency phase refugee camp, should be reinforced.

Pottie K, Janakiram P, Topp P, McCarthy A. Prevalence of selected preventable and treatable diseases among government-assisted refugees: Implications for primary care providers. Can Fam Physician 2007;53:1928-34.

This retrospective cohort study aimed to discover the prevalence of 4 preventable and treatable diseases among newly arriving refugees. The study was, conducted at an immigrant-friendly family medicine centre in Ottawa, Ontario, Canada that offers newly arriving refugees a clinical preventive programme following a specially designed protocol. A total of 112 adult government-assisted refugees seen during 2004 and 2005, within 6 months of their arrival, were included. The main outcome measures were demographic information and prevalence of HIV infection, latent tuberculosis (TB), chronic hepatitis B surface antigen-positive status, and intestinal parasites. 71% of the adults were younger than 35 years and 83% of them had come from sub-Saharan Africa. Disease prevalence rates were 6.3% for HIV (95% confidence interval [CI] 1.8 to 10.8), 49.5% for latent TB (95% CI 39.5 to 49.8), 5.4% for chronic hepatitis B surface antigen-positive status (95% CI 1.2 to 9.5), and 13.6% for intestinal parasites (95% CI 7.2 to 20.0). Most refugees (83%) successfully completed the preventive care programme. Performing chi squared analysis revealed a statistically significant higher risk of latent TB among the men (P < .032). Most of the women had never had a Papanicolaou test. In conclusion, refugees are a vulnerable population with unique, but often preventable or treatable, health issues. This study demonstrated substantial differences in the prevalence of HIV, TB, chronic hepatitis B, and intestinal parasites between government-assisted refugees and Canadian residents. These health disparities and the emerging field of health settlement are new challenges for family physicians and other primary health care providers.

Editors’ note: In 2002 Canada waived the burden-of-illness barriers for refugees who have fled their countries of origin because of well-grounded fears of persecution. Such refugees have higher disease prevalences than the recipient population for HIV, latent TB, chronic hepatitis B surface antigen, and intestinal parasites, reflecting rates in their countries of origin. Health assessments, immunization, and health promotion, including cervical screening for cancer, are key to enhancing the health of all populations, including the government-assisted refugees described in this study.

Morrow M, Arunkumar M, Pearce E, Dawson HE. Fostering disability-inclusive HIV/AIDS programs in northeast India: a participatory study. BMC Public Health 2007;267:125.

Manipur and Nagaland in northeast India are among the Indian states with the highest prevalence of HIV. Most prevention and care programs focus on identified “high risk” groups, but recent data suggest the epidemic is increasing among the general population, primarily through heterosexual sex. People with disability (PWD) in India are more likely than the general population to be illiterate, unemployed, and impoverished, but little is known of their HIV risk. This project aimed to enable HIV programs in Manipur and Nagaland to be more disability-inclusive. The objectives were to: explore HIV risk and risk perception in relation to PWD among HIV and disability programmers, and PWD themselves; identify HIV-related education and service needs and preferences of PWD; and utilise findings and stakeholder consultation to draft practical guidelines for inclusion of disability into HIV programming. Data were collected through a survey and several qualitative tools. The findings revealed that participants believe PWD in these states are potentially vulnerable to HIV transmission due to social exclusion and poverty, lack of knowledge, gender norms, and obstacles to accessing HIV programs. Neither HIV nor disability organisations currently address the risks, needs, and preferences of PWD. The Guidelines produced in the project and disseminated to stakeholders emphasise opportunities for taking action with minimal cost and resources, such as using the networks and expertise of both HIV and disability sectors, producing HIV material in a variety of formats, and promoting accessibility to mainstream HIV education and services. The human rights obligations and public health benefits of modifying national and state policies and programs to assist this highly disadvantaged population are also highlighted.

Editors’ note: This work highlights an important, underrepresented population with an increased risk of contracting HIV. People with disabilities often experience humiliation and social stigma. They may be vulnerable to exploitation, sexual abuse, and assumptions that they are not sexually active, along with decreased access to HIV prevention and care. HIV programmes and disability services providers need to work with disabled people to enable rapid and effective responses to the HIV-related needs of people with visual, hearing, physical, and intellectual impairments.

Coast E. Wasting semen: context and condom use among the Maasai. Cult Health Sex 2007;9:387-401.

Motivations for condom use are intricate and the behaviour of individuals and couples takes place in complex sociocultural settings. This study examines in detail the sociocultural context of condom use among the Maasai, an east African agropastoralist population. A review of the ethno-demographic literature demonstrates the sociocultural significance of semen in a range of settings. A detailed description of Maasai values relating to semen is followed by an analysis presenting results from a sample survey and focus group discussions. Whilst reported knowledge of AIDS was high (100%), unprompted reporting of condoms as a way of preventing HIV infection was low. When asked directly about knowledge of condoms, awareness appeared high but levels of detailed condom knowledge were very low. Of those individuals who reported that they knew what a condom was, only 17% said that they knew how they worked. Focus group discussions reveal strongly held opinions and beliefs connected to condoms and their use, including their contraceptive effects, negative impact on quality of sex, the wasting of semen, and the ‘otherness’ of condoms. The implications of these findings for condom provision and uptake are considered.

Editors’ note: The giving and receiving of semen is valued highly in Maasai culture. Learning the reasoning behind preferences to use or not use condoms can be educational and may be surprising. Understanding “why” and “why not” is the first step in designing programmes to prevent sexual transmission of HIV that will be effective. In the long run, an effective vaginal microbicide might be more acceptable in the Maasai cultural context than male or female condoms.

Krishnan S, Dunbar MS, Minnis AM, Medlin CA, Gerdts CE, Padian NS. Poverty, Gender Inequities and Women’s risk of HIV/AIDS. Ann N Y Acad Sci 2007 Oct 22; [Epub ahead of print]

Entrenched economic and gender inequities together are driving a globally expanding, increasingly female, AIDS epidemic. To date, significant population-level declines in HIV transmission have not been observed at least in part because most approaches to prevention have presumed a degree of individual control in decision-making that does not speak to the reality of women’s and girls’ circumstances in many parts of the world. Such efforts have paid insufficient attention to critical characteristics of the risk environment, most notably poverty and gender-power inequities. Even fewer interventions have addressed specific mechanisms through which these inequities engender risky sexual practices that result in women’s disproportionately increased vulnerabilities to HIV infection. This paper focuses on identifying those mechanisms, or structural pathways, which stem from the interactions between poverty and entrenched gender inequities and recommending strategies to address and potentially modify those pathways. Krishnan and colleagues highlight four such structural pathways to HIV risk, all of which have the potential to be transformed: 1) lack of access to critical information and health services for HIV and sexually transmitted infection (STI) prevention; 2) limited access to formal education and skills development; 3) intimate partner violence; and 4) the negative consequences of migration prompted by insufficient economic resources. The authors argue for interventions that enhance women’s access to education, training, employment, and HIV and STI prevention information and tools; minimize migration; and by working with men and communities, at the same time reduce women’s poverty and promote gender equitable norms. In conclusion, the authors identify challenges in developing and evaluating strategies to address these structural pathways.

Editors’ note: Understanding the multiple dimensions of a risk environment that is impinging on individual “choices” is pivotal to addressing the structural pathways that mediate that risk environment’s influence on behaviour. For example, limited access to education and skills can lead to migration for economic opportunity that may increase the likelihood of transactional sex. Programmes addressing the latter will have limited effect without attention to “upstream” determinants.

Kim JC, Watts CH, Hargreaves JR, Ndhlovu LX, Phetla G, Morison LA, Busza J, Porter JD, Pronyk P. Understanding the impact of a microfinance-based intervention on women’s empowerment and the reduction of intimate partner violence in South Africa. Am J Public Health 2007;97:1794-802.

Kim and colleagues sought to obtain evidence about the scope of women’s empowerment and the mechanisms underlying the significant reduction in intimate partner violence documented by the Intervention With Microfinance for AIDS and Gender Equity (IMAGE) cluster-randomized trial in rural South Africa. The IMAGE intervention combined a microfinance program with participatory training on understanding HIV infection, gender norms, domestic violence, and sexuality.  Outcome measures included past year’s experience of intimate partner violence and 9 indicators of women’s empowerment. Qualitative data about changes occurring within intimate relationships, loan groups, and the community were also collected. Results showed that after two years, the risk of past-year physical or sexual violence by an intimate partner was reduced by more than half (adjusted risk ratio=0.45; 95% confidence interval=0.23, 0.91). Improvements in all 9 indicators of empowerment were observed. Reductions in violence resulted from a range of responses enabling women to challenge the acceptability of violence, expect and receive better treatment from partners, leave abusive relationships, and raise public awareness about intimate partner violence. In conclusion, the authors’ findings, both qualitative and quantitative, indicate that economic and social empowerment of women can contribute to reductions in intimate partner violence.

Editors’ note: Stand alone health programmes can encounter difficulties in recruiting and retaining vulnerable women. This study demonstrates the synergy of deliberately integrating public health interventions into development initiatives, such as microfinance. High uptake of the intervention, consistent village level violence reduction and its congruency with changes in structural pathway variables such as economic well-being and empowerment, and plausible mechanisms suggested by qualitative findings converge to support the effectiveness of this intervention. It should be scaled-up in the context of macro-economic and policy initiatives addressing gender inequities.

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Thomas F. Global rights, local realities: Negotiating gender equality and sexual rights in the Caprivi Region, Namibia. Cult Health Sex 2007;9:599-614.

Gender inequalities are frequently cited as a major reason for high HIV-prevalence rates in southern Africa. While steps have been taken to promote and pass legislation that upholds equal rights for women, this paper examines the ways in which discourses of gender equality and ensuing sexual rights can have complex, contradictory, and even adverse implications when they are mobilised, resisted, and reinterpreted at local level. Drawing upon research undertaken in the Caprivi Region of Namibia, this paper examines the ways in which men and women respond to ideas about gender equality, and seeks to place these responses within the wider context of socio-economic change and understandings of morality prevalent within the region. The tendency of many young women to seek out relationships with older men and the increasing costs of bride-wealth payments play a key role in reinforcing patriarchal attitudes and fuelling non respect for women’s rights both before and within marriage. In addition, a failure to adhere to customary norms, which uphold men’s dominant role, continues to threaten the support networks and assets available to women. The consequences of this situation are examined with particular focus on implications for the future transmission of HIV.

Editors’ note: This paper describes a “catch-22” situation in which adherence to the customary norms that can undermine women’s civil rights is necessary for women to access the social and economic entitlements they need for day-to-day subsistence. Promoting sexual rights and gender equality requires looking for openings and creating opportunities for negotiation to change customary norms so that they build on locally accepted core values such as respect, fairness, and justice. Only then will enforcement of national legislation promoting gender equality find fertile ground.