HIV This Week

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.

Wilson DP, Law MG, Grulich AE, Cooper DA, Kaldor JM. Relation between HIV viral load and infectiousness: a model-based analysis. Lancet. 2008;372(9635):314-20.

A consensus statement released on behalf of the Swiss Federal Commission for HIV/AIDS suggests that people receiving effective antiretroviral therapy-ie, those with undetectable plasma HIV RNA (<40 copies per mL)-are sexually non-infectious. Wilson and colleagues analysed the implications of this statement at a population level. They used a simple mathematical model to estimate the cumulative risk of HIV transmission from effectively treated HIV-infected patients (HIV RNA <10 copies per mL) over a prolonged period. The authors investigated the risk of unprotected sexual transmission per act and cumulatively over many exposures, within couples initially discordant for HIV status. Assuming that each couple had 100 sexual encounters per year, the cumulative probability of transmission to the serodiscordant partner each year is 0.0022 (uncertainty bounds 0.0008-0.0058) for female-to-male transmission, 0.0043 (0.0016-0.0115) for male-to-female transmission, and 0.043 (0.0159-0.1097) for male-to-male transmission. In a population of 10 000 serodiscordant partnerships, over 10 years the expected number of seroconversions would be 215 (80-564) for female-to-male transmission, 425 (159-1096) for male-to-female transmission, and 3524 (1477-6871) for male-to-male transmission, corresponding to an increase in incidence of four times compared with incidence under current rates of condom use. The analyses suggest that the risk of HIV transmission in heterosexual partnerships in the presence of effective treatment is low but non-zero and that the transmission risk in male homosexual partnerships is high over repeated exposures. If the claim of non-infectiousness in effectively treated patients was widely accepted, and condom use subsequently declined, then there is the potential for substantial increases in HIV incidence.

Editors’ note: This modelling suggests that, at the population level, treatment as a prevention strategy would not be an improvement over condom use. This model assumes that a threshold viral load under which transmission is very difficult does not exist, something that we do not know, and uses estimates of average HIV transmission probabilities that are unlikely to apply to all discordant couples. Nonetheless, the estimates are sobering and suggest that as a population strategy, treatment as prevention has the potential to reduce HIV epidemics only if consistent condom use is maintained. This conclusion is supported by resurgence of HIV among populations with high levels of treatment, such as men who have sex with men in Amsterdam.

Lima and colleagues developed a mathematical model using a multiple source of infection framework to assess the potential effect of the expansion of highly active antiretroviral therapy coverage among those in medical need on the number of individuals testing newly positive for human immunodeficiency virus (HIV) and on related costs in British Columbia, Canada, over the next 25 years. The model was calibrated using retrospective data describing antiretroviral therapy utilization and individuals testing newly positive for HIV in the province. Different scenarios were investigated on the basis of varying assumptions regarding drug resistance, adherence to highly active antiretroviral therapy, therapeutic guidelines, degree of highly active antiretroviral therapy coverage, and the timing of highly active antiretroviral therapy uptake. Expansion of highly active antiretroviral therapy leads to substantial reductions in the growth of the HIV epidemic and related costs. These results provide powerful additional motivation to accelerate the roll out of highly active antiretroviral therapy programmes aggressively targeting those in medical need, both for their own benefit and as a means of decreasing new HIV infections.

Editors’ note: This model estimates encouraging effects of treatment at the population level when all current HIV prevention modalities are maintained. These include promotion and provision of condoms, needles and syringes, and methadone maintenance, in addition to reduction in the number of sex partners. The model suggests that for expansion of treatment to be a successful complementary strategy, HIV testing must expand to increase knowledge of serostatus. Clearly, expanded access to antiretroviral treatment could be a supplement but not a replacement for current HIV prevention programming.

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.