HIV This Week

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.

  

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.

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Ntaganira J, Muula AS, Masaisa F, Dusabeyezu F, Siziya S, Rudatsikira E. Intimate partner violence among pregnant women in Rwanda. BMC Womens Health. 2008;8:17.

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.

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.

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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.

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