Nwabisa Jama Shai

Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study

BACKGROUND Cross-sectional studies have shown that intimate partner violence and gender inequity in relationships are associated with increased prevalence of HIV in women. Yet temporal sequence and causality have been questioned, and few HIV prevention programmes address these issues. We assessed whether intimate partner violence and relationship power inequity increase risk of incident HIV infection in South African women. METHODS We did a longitudinal analysis of data from a previously published cluster-randomised controlled trial undertaken in the Eastern Cape province of South Africa in 2002-06. 1099 women aged 15-26 years who were HIV negative at baseline and had at least one additional HIV test over 2 years of follow-up were included in the analysis. Gender power equity and intimate partner violence were measured by a sexual relationship power scale and the WHO violence against women instrument, respectively. Incidence rate ratios (IRRs) of HIV acquisition at 2 years were derived from Poisson models, adjusted for study design and herpes simplex virus type 2 infection, and used to calculate population attributable fractions. FINDINGS 128 women acquired HIV during 2076 person-years of follow-up (incidence 6.2 per 100 person-years). 51 of 325 women with low relationship power equity at baseline acquired HIV (8.5 per 100 person-years) compared with 73 of 704 women with medium or high relationship power equity (5.5 per 100 person-years); adjusted multivariable Poisson model IRR 1.51, 95% CI 1.05-2.17, p=0.027. 45 of 253 women who reported more than one episode of intimate partner violence at baseline acquired HIV (9.6 per 100 person-years) compared with 83 of 846 who reported one or no episodes (5.2 per 100 person-years); adjusted multivariable Poisson model IRR 1.51, 1.04-2.21, p=0.032. The population attributable fractions were 13.9% (95% CI 2.0-22.2) for relationship power equity and 11.9% (1.4-19.3) for intimate partner violence. INTERPRETATION Relationship power inequity and intimate partner violence increase risk of incident HIV infection in young South African women. Policy, interventions, and programmes for HIV prevention must address both of these risk factors and allocate appropriate resources. FUNDING National Institute of Mental Health and South African Medical Research Council.

Associations between depressive symptoms, sexual behaviour and relationship characteristics: a prospective cohort study of young women and men in the Eastern Cape, South Africa

BackgroundPsychological factors are often neglected in HIV research, although psychological distress is common in low- to middle-income countries, such as South Africa. There is a need to deepen our understanding of the role of mental health factors in the HIV epidemic. We set out to investigate whether baseline depressive symptomatology was associated with risky sexual behaviour and relationship characteristics of men and women at baseline, as well as those found 12 months later.MethodsWe used prospective cohort data from a cluster randomized controlled trial of an HIV prevention intervention in the Eastern Cape Province of South Africa. Our subjects were 1002 female and 976 male volunteers aged 15 to 26. Logistic regression was used to model the cross-sectional and prospective associations between baseline depressive symptomatology, risky sexual behaviors and relationship characteristics. The analysis adjusted for the clustering effect, study design, intervention and several confounding variables.ResultsPrevalence of depressive symptoms was 21.1% among women and 13.6% among men. At baseline, women with depressed symptoms were more likely to report lifetime intimate partner violence (AOR = 2.56, 95% CI 1.89-3.46) and have dated an older partner (AOR = 1.37, 95% CI 1.03-1.83). A year later, baseline depressive symptomatology was associated with transactional sex (AOR = 2.60, 95% CI 1.37, 4.92) and intimate partner violence (AOR = 1.67, 95% CI 1.18-2.36) in the previous 12 months. Men with depressive symptoms were more likely to report ever having had transactional sex (AOR = 1.48, 95% CI 1.01-2.17), intimate partner violence perpetration (AOR = 1.50, 95% CI 0.98-2.28) and perpetration of rape (AOR = 1.81, 95% CI 1.14-2.87). They were less likely to report correct condom use at last sex (AOR = 0.50, 95% CI 0.32-0.78). A year later, baseline depressive symptomatology was associated with failure to use a condom at last sex among men (AOR = 0.60, 95% CI 0.40-0.89).ConclusionsSymptoms of depression should be considered as potential markers of increased HIV risk and this association may be causal. HIV prevention needs to encompass promotion of adolescent mental health.

Transactional Sex and HIV Incidence in a Cohort of Young Women in the Stepping Stones Trial

Background: Structural drivers of the HIV epidemic are increasingly recognised, and cross-sectional research has shown an association between transactional sex and HIV prevalence, but evidence on the impact of transactional sex on HIV incidence in young women remains limited. Methods: We tested hypotheses that transactional sex predicted incident HIV infections in a dataset of 1077 HIV negative women aged 15-26 enrolled in a cluster randomised controlled trial. Incidence rate ratios were derived from multivariable Poisson models which included terms for age, HSV2, relationship power, condom use, intimate partner violence (IPV) exposure, treatment, stratum and person years of exposure to HIV. Results: 127 sexually active women acquired HIV during the study. HIV incidence was greater among women having transactional sex with a once off partner (IRR 3.29 95% CI 1.02, 10.55, p=0.046) and those having transactional sex with an on-going, concurrent partner (IRR 2.05 95% CI 1.20, 3.52, p=0.009). An analysis was performed to distinguish between the effects of a transactional sexual encounter or relationship and having a higher number of sexual partners or older partners, which are usually entailed in transactional sex. Women having transactional sex with a casual partner (on-going or once off) and two or more partners during follow up had an elevated risk of HIV acquisition (IRR 2.23 95% CI 1.28, 3.88, p=0.005), where as those just having two or more partners did not (IRR 1.20 95% CI 0.81, 1.77, p=0.368). Women with partners 5 or more years older did not have an elevated risk of HIV. Conclusions: Transactional sex with an on-going or once off partner elevates young women’s risk of HIV infection. This finding is independent of partner number or age. These findings support the need for structural interventions in HIV prevention, with a stronger focus on reducing transactional sex.

Factors associated with consistent condom use among rural young women in South Africa

Abstract Despite high levels of awareness of HIV, condom use, particularly consistent use, is suboptimal among young South African women. This paper aims to investigate the factors associated with both any condom use and consistent use by young rural women. In this study 1204 sexually active female volunteers, aged 15–26 years, were selected using a two-stage procedure in which firstly 70 clusters were selected and thereafter up to 20 women per cluster were selected, to participate in a cluster randomised controlled trial of an HIV behavioural intervention. This study is analysing cross-sectional data from a baseline survey thus no causal inferences can be drawn. A structured questionnaire was administered at a baseline interview. An estimated 19.9% of young women reported consistent condom use in the 12 months before the interview, while 44.5% reported inconsistent use. Any condom use was associated with higher condom use self-efficacy (adjusted odds ratio (aOR) 1.59; 95% CI 1.41, 1.77), less association of trust with suggested condom use (aOR 0.86; 95% CI 0.82, 0.91), knowing ones HIV status (aOR 2.86; 95% CI 1.52, 5.39) and having a more educated mother (aOR 1.71; 95% CI 1.26, 2.33). Having had just one partner was associated with a lesser likelihood of any condom use (aOR 0.14; 95% CI 0.10, 0.20). Consistent use, compared with inconsistent use, was associated with having just one partner (aOR 3.25; 95% CI 2.23, 4.73), less relationship conflict (aOR 0.84; 95% CI 0.75, 0.91) and higher gender equity in relationships with a male partner (aOR 1.43; 95% CI 1.15, 1.77). Our findings suggest that gender equity, monogamy and harmonious relationships play a positive role in enabling women to reduce their risk for HIV infection. Such aspects of relationship context could form a significant part of the progressive strategies required for HIV-prevention interventions to be successful.

Adverse Mental Health Outcomes Associated With Emotional Abuse in Young Rural South African Women A Cross-Sectional Study

There is a lack of data on the prevalence of emotional abuse in youth. The aim of this study was thus to estimate the prevalence of emotional abuse in intimate partnerships among young women in rural South Africa and to measure the association between lifetime experience of emotional abuse (with and without the combined experience of physical and/or sexual abuse) and adverse health outcomes. Between 2002 and 2003, young women from 70 villages were recruited to participate in the cluster randomized controlled trial of an HIV behavioral intervention, Stepping Stones. Data was obtained through the administration of a questionnaire at baseline. Of the 1,293 women who had ever been partnered, 189 (14.6%) had experienced only emotional abuse in their lifetimes. Three hundred sixty-six women (28.3%) experienced emotional abuse with physical and/or sexual abuse in their lifetimes, and one hundred forty-four women (11.1%) experienced physical and/or sexual abuse without emotional abuse. Hazardous drinking was associated with the experience of physical and/or sexual abuse, with (OR 6.0, 95% CI [1.0, 36.6]) and without emotional abuse (OR 5.8, 95% CI [1.1, 29.4]). Illicit drug use (OR 5.6, 95% CI [2.4, 12.6]), having depressive symptoms (OR 2.9, 95% CI [1.2, 4.2]), having psychological distress (OR 1.9, 95% CI [1.4, 2.6]), and suicidality (OR 79.0, 95% CI [17.3, 359.6]) was associated with the experience of emotional abuse with physical and/or sexual abuse. Suicidality was also strongly associated with having experienced emotional abuse alone (OR 79.5, 95% CI [16.7, 377.4]). This study showed that emotionally abused young women had a greater risk of suicidality than those experiencing no abuse and that the combined experience of emotional with physical and/or sexual abuse was strongly associated with poor mental health outcomes.

Motivations for, and perceptions and experiences of participating in, a cluster randomised controlled trial of a HIV-behavioural intervention in rural South Africa

Empirical research on ethical issues in HIV-prevention and gender-based violence research, critical for honing ethical and safety guidelines, is limited. In this paper we describe South African young peoples motivations for participating in randomised controlled trial, the prevalence of negative occurrences, participation regrets and associated factors. This trial partly followed, but also deviated from, the WHO safety guidelines for research on violence against women. A total of 1085 women and 985 men provided information two years after the trial start. Most participated for HIV testing and to help their community. Fewer reported motivation by the financial incentive. Minor adverse events included upset from questions on childhood experiences and arguments at home with siblings. Just under 1 in 10 (8.1% women, 9.8% men) regretted participation. Factors were associated with this were keeping some questions secret from their partners, feeling sad about questions on childhood, quarrelling at home and, for women, being motivated by the incentive. Men who had been physically violent to a partner were twice as likely to regret participation. There were no recorded adverse effects from the deviations from the ethical guidelines. Participation regrets mostly stemmed from problems in participants’ families preceding the research. There was no evidence that the research had been unsafe.

Prevalence and factors associated with depressive symptoms among young women and men in the Eastern Cape Province, South Africa

Purpose: There is little research on prevalence of depressive symptoms and associated factors among youth in sub-Saharan Africa. This paper explores factors associated with depressive symptomatology in South Africa. Methods: A cross-sectional analysis of interviews with 1 415 women and 1 368 men aged 15–26 was undertaken. The Centre for Epidemiological Studies on Depression Scale (CESD Scale) was used to establish depressive symptomatology. Results: The prevalence of depressive symptoms was 20.5% in women and 13.5% in men. For women, depressive symptoms were associated with increased childhood adversity (aOR 1.34 95% CI 1.116, 1.55); drug use (aOR 1.98 CI 1.17, 3.35); experience of intimate partner violence (aOR 2.21 CI 1.16, 3.00); sexual violence before the age of 18 years (aOR 1.45 CI 1.02, 2.02) and lower perceptions of community cohesion (aOR 1.23 CI 1.07, 1.40). For men, depressive symptoms were associated with a mothers death (aOR 2.24 CI 1.25, 4.00); childhood adversity (aOR 1.61 CI 1.38, 1.88); alcohol abuse (aOR 1.63 CI 1.13, 2.35), sexual coercion by a woman (aOR 2.36 CI 1.47, 3.80) and relationship conflict (aOR 1.07 CI 1.01, 1.12). Conclusions: Depressive symptoms were more highly prevalent in women than in men. Depressed mood was associated with childhood adversity, sexual violence and substance misuse in both women and men. This study further suggests gender differences in that for women, depressive symptoms were associated with intimate partner violence and lower perceptions of community cohesion, while for men the associations were with a mothers death and relationship conflict.

Creating Futures: lessons from the development of a livelihood-strengthening curriculum for young people in eThekwini's informal settlements

Comprehending praxis is a critical step in developing interventions that can have a real-world impact on peoples lives. In this paper, we reflect on the lessons learned in the development of a curriculum for young people living in informal settlements in eThekwini, who are exposed to numerous vulnerabilities, including HIV-related risks associated with precarious urban livelihoods. Behavioural interventions have not led to commensurate reductions in HIV incidence, and the impact of these approaches remains regulated by numerous contextual conditions affecting those participating. Our collaborative project tested the impact of implementing a combination of the well-tested gender transformation intervention, Stepping Stones, with a new livelihood transformation curriculum, Creating Futures, among young people in eThekwinis informal settlements. Creating Futures was grounded in the theory and practice of sustainable livelihoods, but equally in the experience of the multi-disciplinary project team members who have conducted both research and development work among youth in the eThekwini area. Our approach was founded on the work of Doug Kirby, and we are indebted to him for his inputs. His logical model approach ensured that the team remained orientated to specific curriculum outcomes. Analysis of the results at 12 months post-baseline indicates positive livelihood outcomes.

Perpetration of physical and sexual abuse and subsequent fathering of pregnancies among a cohort of young South African men: a longitudinal study

BackgroundYoung men’s involvement in fathering pregnancies has been substantially neglected in unintended pregnancy research. Gender norms give men substantial power and control over sexual encounters, suggesting that understanding men’s role is imperative. We tested the hypothesis that young, unmarried South African men who had perpetrated intimate partner violence (IPV) have a greater incidence of fathering pregnancies.MethodsThe data for this study were collected from 983 men aged 15 to 26 who participated in a 2-year community randomized controlled HIV prevention trial in the rural Eastern Cape. Multivariate Poisson models investigated the associations between baseline perpetration of IPV and fathering subsequent pregnancies, while controlling for age, number of sexual partners, socio-economic status, educational attainment, problematic alcohol use, exposure to the intervention, and time between interviews.ResultsOf the men in this study, 16.5% (n = 189) had made a girlfriend pregnant over two years of follow up. In addition, 39.1% had perpetrated physical or sexual intimate partner violence and 24.3% had done so more than once. Men who at baseline had perpetrated IPV in the previous year had an increased incidence of fathering, for a first perpetration in that year IRR 1.67 (95% CI 1.14-2.44) and among those who had also been previously violent, IRR 1.97 (95% CI 1.31-2.94). Those who had ever been violent, but not in the past year, did not have an elevated incidence. The incidence among men who had ever perpetrated physical abuse was less elevated than among those who had perpetrated physical and sexual violence IRR 1.64 (95% CI 1.18-2.29) versus IRR 2.59 (95% CI 1.64-4.10) indicating a dose response.ConclusionYoung men’s perpetration of partner violence is an important predictor of subsequently fathering a pregnancy. The explanation may lie with South African hegemonic masculinity, which valorizes control of women and displays of heterosexuality and virility, and compromises women’s reproductive choices.

I was in the darkness but the group brought me light: Development, relevance and feasibility of the Sondela HIV adjustment and coping intervention

Developing interventions that address psychosocial wellbeing of people living with HIV is critical to ensure strong linkages to and retention in HIV care. This paper describes the development of Sondela, an HIV adjustment and coping intervention for heterosexual men and women living with HIV, and its relevance and feasibility in the South African context. Sondela is a six three-hour, small group-based, participatory workshop series. We followed an iterative, multi-phased process of curriculum development that involved research, theoretical frameworks and piloting. A systematic review highlighted the absence of psychosocial interventions targeting heterosexual HIV positive populations living in high HIV prevalence and resource-poor settings. Formative studies demonstrated risk and social factors associated with adjustment and coping with HIV, emphasising the need for interventions that acknowledge gendered experiences. Our pilot of Sondela demonstrated high levels of relevance and feasibility. Men appreciated the workshop “space” to openly talk about their HIV positive status and what is means for their role as partners and fathers and friends. Women valued the skills and approaches because they were relevant to “real life” situations and not just about HIV. Sondela promises to be valuable in supporting health system initiatives and psychosocial support to strengthen linkages to and retention in HIV care, and this suggests a need for rigorous evaluation of Sondela to establish evidence for its effectiveness in a general population.