Sara Yeatman

Increasing the acceptability of HIV counseling and testing with three C's: Convenience, confidentiality and credibility

Agencies engaged in humanitarian efforts to prevent the further spread of HIV have emphasized the importance of voluntary counseling and testing (VCT), and most high-prevalence countries now have facilities that offer testing free of charge. The utilization of these services is disappointingly low, however, despite high numbers reporting that they would like to be tested. Explanations of this discrepancy typically rely on responses to hypothetical questions posed in terms of psychological or social barriers; often, the explanation is that people fear learning that they are infected with a disease that they understand to be fatal and stigmatizing. Yet when we offered door-to-door rapid blood testing for HIV as part of a longitudinal study in rural Malawi, the overwhelming majority agreed to be tested and to receive their results immediately. Thus, in this paper, we ask: why are more people not getting tested? Using an explanatory research design, we find that rural Malawians are responsive to door-to-door HIV testing for the following reasons: it is convenient, confidential, and the rapid blood test is credible. Our study suggests that attention to these factors in VCT strategies may mitigate the fear of HIV testing, and ultimately increase uptake in rural African settings.

Uncertainty and Fertility in a Generalized AIDS Epidemic.

Sociologists widely acknowledge that uncertainty matters for decision making, but they rarely measure it directly. In this article, we demonstrate the importance of theorizing about, measuring, and analyzing uncertainty as experienced by individuals. We adapt a novel probabilistic solicitation technique to measure personal uncertainty about HIV status in a high HIV prevalence area of southern Malawi. Using data from 2,000 young adults (ages 15 to 25 years), we demonstrate that uncertainty about HIV status is widespread and that it expands as young adults assess their proximate and distant futures. In conceptualizing HIV status as something more than sero-status itself, we gain insight into how what individuals know they don’t know influences their lives. Young people who are uncertain about their HIV status express desires to accelerate their childbearing relative to their counterparts who are certain they are uninfected. Our approach and findings show that personal uncertainty is a measurable and meaningful phenomenon that can illuminate much about individuals’ aspirations and behaviors.

Men's heightened risk of AIDS-related death: the legacy of gendered HIV testing and treatment strategies.

Women are frequently depicted as the face of AIDS in sub-Saharan Africa (SAA) [1–3] where they comprise nearly 58% of all reported HIV infections [4]. Donor dollars, policies, and HIV programs have followed suit, resulting in a near-exclusive focus on women [e.g. 5]. Although African women are represented as particularly vulnerable to HIV infection [6], it is men, not women, who are more likely to die of AIDS [7–9]. AIDS prevalence may have the face of a woman, but AIDS mortality has the face of a man.

Stability and Change in Fertility Preferences Among Young Women in Malawi

CONTEXT Although studies have demonstrated change in fertility preferences over time, there is a lack of definitive knowledge about the level and direction of change among individuals, especially young and unmarried women. Furthermore, little is known about the factors associated with changes in fertility preferences over time. METHOD The analysis uses the first five waves of data from a longitudinal study of a random sample of women aged 15-25 in southern Malawi. The data were collected four months apart over an 18-month period, between June 2009 and December 2010. Multinomial logit regression models were used to calculate relative risk ratios and identify associations between four categories of life events-reproductive, relationship, health and economic-and shifts in fertility timing preferences. RESULTS In each four-month period, more than half of the women reported changes in the desired timing of their next birth, and delays and accelerations in timing desires were common. Several life events, including having a child, entering a serious relationship and changes in household finances were associated with changes in the level and direction of fertility preference. CONCLUSION Shifts in fertility timing preferences often occur in response to changes in life circumstances. Understanding the reasons for these shifts may aid family planning providers in meeting womens contraceptive needs.

The relationship between orphanhood and child fostering in sub-Saharan Africa, 1990s–2000s

In countries most afflicted by HIV/AIDS in sub-Saharan Africa, orphanhood has increased dramatically, but the potential consequences of the increase have been mitigated by the ability of households to absorb orphans. This paper examines what the rising levels of orphanhood mean for the common practice of non-orphan child fostering in regions of high and low HIV prevalence in sub-Saharan Africa, which has a long history of child fostering. Using Demographic and Health Survey data from 135 regions within 14 sub-Saharan countries that undertake HIV testing and have had at least two surveys, we examine changes in fostering patterns. In most regions, we find a more accommodating relationship between orphan and non-orphan fostering: communities are able to absorb the demand for both orphans and non-orphans. Where HIV prevalence exceeds 10 per cent there is some evidence that the need to care for orphans is beginning to reduce opportunities for non-orphan fostering.

The Impact of Family Transitions on Child Fostering in Rural Malawi

Despite the frequency of divorce and remarriage across much of sub-Saharan Africa, little is known about what these events mean for the living arrangements of children. We use longitudinal data from rural Malawi to examine the effects of family transitions on the prevalence and incidence of child fostering, or children residing apart from their living parents. We find that between 7 % and 15 % of children aged 3–14 are out-fostered over the two-year intersurvey period. Although divorce appears to be a significant driver of child fostering in the cross-sectional analysis, it is not significantly associated with the incidence of out-fostering. In contrast, maternal remarriage has both a lagged and an immediate effect on the incidence of out-fostering. Furthermore, the likelihood of out-fostering is even higher among children whose mother remarried and had a new child during the intersurvey period. Using longitudinal data collected from living mothers rather than from children’s current foster homes offers new insights into the reasons children are sent to live with others besides their parents.

The social construction of AIDS during a time of evolving access to antiretroviral therapy in rural Malawi

This paper draws upon a set of conversational journals collected over the past decade in rural Malawi, to understand how perceptions of AIDS are constructed as talk of antiretroviral therapy (ART) filters through social networks. Three distinct treatment eras frame our analysis: the early ART era (2001–2003), the ART expansion era (2004–2006) and the later ART era (2007–2009). We find that the early ART era was characterised by widespread fatalism as people recalled experiences with dying family and friends from what was perceived as an incurable and deadly disease. During the ART expansion era, AIDS fatalism was gradually replaced with a sense of uncertainty as rural Malawians became faced with two opposing realities: death from AIDS and prolonged life after ART. In the later ART era, the journals chart the rise of more optimistic beliefs about AIDS as rural Malawians slowly became convinced of ARTs therapeutic payoffs. We conclude with an example of how ART created difficulties for rural Malawians to socially diagnose the disease and determine who was a safe sexual partner.

'HIV is an enemy of childbearers': the construction of local epidemiology in rural Malawi

In the sub-Saharan African AIDS epidemic there is no shortage of formal messages about HIV distributed through health clinics, NGOs and the media. These messages, however, do not always address the issues that are of most importance for people living in the epidemic and learning how to navigate it safely. In rural Malawi, one message that has been absent concerns the implications of HIV for childbearing. Using data from in-depth interviews, this paper argues that rural Malawians socially constructed their own belief system and came to believe strongly that pregnancy and childbirth would negatively impact the disease progression of HIV-positive women. Through the recursive processes of selective observation, interpretation of formal public health messages and discussion within social networks, rural Malawians concluded that HIV and childbearing did not go together. In an uncertain world, social constructive processes such as these that are fluid and responsive to local circumstances are particularly important for making sense of the seemingly senseless and for developing tools to navigate unsettled times.

Impact of ART on the Fertility of HIV-Positive Women in Sub-Saharan Africa.

Understanding the fertility of HIV‐positive women is critical to estimating HIV epidemic trends from surveillance data and to planning resource needs and coverage of prevention of mother‐to‐child transmission services in sub‐Saharan Africa. In the light of the considerable scale‐up in antiretroviral therapy (ART) coverage over the last decade, we conducted a systematic review of the impact of ART on the fertility outcomes of HIV‐positive women.

Best-Friend Reports: A Tool for Measuring the Prevalence of Sensitive Behaviors

We introduce the best-friend methodology for using surveys to measure the population prevalence of sensitive behaviors. We demonstrate the effectiveness of this tool by comparing self-reports to best-friend reports of sexual behavior and abortion history among young women in Malawi (n = 1493). Best-friend reports reveal higher and more believable estimates of abortion and multiple sexual partners. In contexts in which best friends commonly discuss such behaviors, best-friend reports are an inexpensive and easily implemented tool.