Characteristics of Age-Discordant Partnerships Associated with HIV Risk among Young South African Women

OBJECTIVE:

Sexual liaisons between older men and younger women have been linked to greater risk of HIV acquisition. This study aims to: 1) identify psychosocial and behavioral factors associated with age-discordant (partner ≥ 5 years older) versus age-concordant partnerships (-1<partner< 5); and 2) examine the association between partner age discordance and young South African women's sexual behavior.

METHODS:

We used generalized estimating equations to analyze responses from 656 sexually-experienced females (aged 13-20 years) from rural Mpumalanga province.

RESULTS:

Partner age discordance was associated with greater odds of reporting both more frequent sex and having a partner with concurrent partnerships. Age-discordant partnerships were associated with greater odds of: casual partnerships, having a partner with concurrent partnerships and more frequent intercourse (i.e., having sex at least 2 or 3 times per month). They were associated with lower odds of reporting condom use at last sex and always using condoms in age-discordant partnerships.

CONCLUSION:

Our findings suggest that a history of age-discordant partnerships, and to a lesser extent having an age-discordant partner, is linked to HIV risk among young South African women; however, the link between partner age discordance and HIV risk may be more strongly related to the characteristics of age-discordant partnerships than to characteristics of young women who form such partnerships.

Purchase PDF full article at:  http://goo.gl/QTPiAc

By:  Ritchwood TD1, Hughes JP, Jennings L, MacPhail C, Williamson B, Selin A, Kahn K, Gómez-Olivé FX, Pettifor A.

• 1 Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC.  
• 2 Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA. 
• 3 Fred Hutchinson Cancer Research Institute, Seattle, WA.
• 4 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. 
• 5 School of Health, University of New England, Armidale, NSW. 
• 6 Wits Reproductive Health & HIV Institute, University of the Witwatersrand, Johannesburg, South Africa. 
• 7 Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
• J Acquir Immune Defic Syndr. 2016 Mar 11. 

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Intimate Partner Violence and Depression Symptom Severity among South African Women during Pregnancy and Postpartum

Background

Violence against women by intimate partners remains unacceptably common worldwide. The evidence base for the assumed psychological impacts of intimate partner violence (IPV) is derived primarily from studies conducted in high-income countries. A recently published systematic review identified 13 studies linking IPV to incident depression, none of which were conducted in sub-Saharan Africa. To address this gap in the literature, we analyzed longitudinal data collected during the course of a 3-y cluster-randomized trial with the aim of estimating the association between IPV and depression symptom severity.

Methods and Findings

We conducted a secondary analysis of population-based, longitudinal data collected from 1,238 pregnant women during a 3-y cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 mo, 18 mo, and 36 mo (85% retention). The primary explanatory variable of interest was exposure to four types of physical IPV in the past year. Depression symptom severity was measured using the Xhosa version of the ten-item Edinburgh Postnatal Depression Scale. In a pooled cross-sectional multivariable regression model adjusting for potentially confounding time-fixed and time-varying covariates, lagged IPV intensity had a statistically significant association with depression symptom severity (regression coefficient b = 1.04; 95% CI, 0.61–1.47), with estimates from a quantile regression model showing greater adverse impacts at the upper end of the conditional depression distribution. Fitting a fixed effects regression model accounting for all time-invariant confounding (e.g., history of childhood sexual abuse) yielded similar findings (b = 1.54; 95% CI, 1.13–1.96). The magnitudes of the coefficients indicated that a one–standard-deviation increase in IPV intensity was associated with a 12.3% relative increase in depression symptom severity over the same time period. The most important limitations of our study include exposure assessment that lacked measurement of sexual violence, which could have caused us to underestimate the severity of exposure; the extended latency period in the lagged analysis, which could have caused us to underestimate the strength of the association; and outcome assessment that was limited to the use of a screening instrument for depression symptom severity.

Conclusions

In this secondary analysis of data from a population-based, 3-y cluster-randomized controlled trial, IPV had a statistically significant association with depression symptom severity. The estimated associations were relatively large in magnitude, consistent with findings from high-income countries, and robust to potential confounding by time-invariant factors. Intensive health sector responses to reduce IPV and improve women’s mental health should be explored.

Below:  Kernel density plots of depression symptom severity, by type and frequency of intimate partner violence.  The scale includes items inquiring about the frequency with which a women’s current or previous intimate partner had, during the past 12 mo, (A) slapped or thrown anything at her; (B) pushed or shoved her; (C) hit her with a fist or another object; or (D) threatened or attacked her with a gun, knife, or other weapon.

Full article at:   http://goo.gl/nm1AsI

By:  Tsai AC1,2,3, Tomlinson M4, Comulada WS5,6, Rotheram-Borus MJ5,6.

• 1Massachusetts General Hospital, MGH Global Health, Boston, Massachusetts, United States of America.
• 2Harvard Center for Population and Development Studies, Cambridge, Massachusetts, United States of America.
• 3Mbarara University of Science and Technology, Mbarara, Uganda.
• 4Stellenbosch University, Stellenbosch, South Africa.
• 5Center for HIV Identification, Prevention and Treatment Services, University of California at Los Angeles, Los Angeles, California, United States of America.
• 6Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, California, United States of America. 
• PLoS Med. 2016 Jan 19;13(1):e1001943. doi: 10.1371/journal.pmed.1001943. eCollection 2016.

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Histories of Forced Sex & Health Outcomes among Southern African Lesbian & Bisexual Women

Experiences of forced sex have been shown to be prevalent in Southern Africa. Negative outcomes of forced sex have been documented in general populations of women and men and include alcohol abuse, drug use, mental health problems, mental distress, sexual health problems and poor overall health. This study is the first to examine experiences of forced sex and associated health problems among lesbian and bisexual women in Southern Africa.

METHODS:

This study is based on data collected as part of a collaborative endeavor involving various Southern African community-based organizations. Lesbian and bisexual women in four Southern African countries participated in a cross-sectional survey, for a total study sample of 591.

RESULTS:

Nearly one-third of participants had been forced to have sex at some time in their lives. Thirty-one percent of all women reported to have experienced forced sex at least once in their life: 14.9% reported forced sex by men only; 6.6% reported forced sex by women only; 9.6% had had forced sexual experiences with both men and women. Participants experienced forced sex by men as more serious than forced sex by women; forced sex by women was more likely to involve intimate partners compared to forced sex by men. Participants who experienced forced sex by men were more likely to report drug problems, mental distress and lower sense of belonging. Forced sex by women was associated with drinking problems and mental distress. Having experienced forced sex by both men and women was associated with lower sense of belonging to the LGBT community, drug use problem and mental distress.

CONCLUSIONS:

The findings indicate that forced sex among Southern African women is a serious issue that needs further exploration. Clinicians should be made aware of the prevalence and possible consequences of forced sex among lesbian and bisexual women. Policies and community interventions should be designed to address this problem.

Table 2

Characteristics of forced sex experiences (by cases of forced sex (%)) 1

	Forced by men	Forced by women
	(n = 145)	(n = 96)	χ 2
Perpetrator was intimate partner	51 (36.4)	55 (59.1)	10.09*
Perpetrator known to participant			3.29
Known	87 (65.9)	68 (77.3)
Some known and some unknown	15 (11.4)	7 (8.0)
Unknown	30 (22.7)	13 (14.8)
Frequency of experience			1.31
Once	61 (46.2)	36 (41.9)
More than once	71 (53.8)	50 (58.1)
Type of sex2
Fingers or objects in vagina	55 (50.9)	34 (45.3)
Fingers or objects in anus	22 (21.0)	16 (23.5)
Oral sex on participant	34 (32.7)	34 (46.6)
Oral sex on forcing partner	48 (44.9)	42 (56.0)
Penis in vagina	108 (85.0)	---
Penis in anus	34 (31.5)	---
Stimulated vagina of participant	---	47 (60.3)
Stimulated vagina of forcing partner	---	40 (54.8)
Seriousness			29.7*
Not serious at all	32 (22.9)	37 (40.2)
Somewhat serious	16 (11.4)	25 (27.2)
Serious	29 (20.7)	17 (18.5)
Very serious	63 (45.0)	13 (14.1)

1N’s may not sum to total due to missing data; percentages reported are percent of valid data.

2Type of sex is percent of total reporting forced sex by this gender; respondents could report more than one type of sex. Differences between proportions not tested.

*p < .001.

Full article at:   http://goo.gl/97nhON

By:   Theo Sandfort, M Somjen Frazer, Zethu Matebeni, Vasu Reddy, Ian Southey-Swartz, and Southern African Lesbian and Bisexual Women Research Team

HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY USA

Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY USA

Institute for Humanities in Africa, HUMA, University of Cape Town, Rondebosch, South Africa

Human Sciences Research Council, Human and Social Development Programme, Pretoria, South Africa and University of KwaZulu-Natal, Durban, South Africa

Open Society Initiative for Southern Africa, Johannesburg, South Africa

Division of Gender Sexuality and Health, Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032 USA

Theo Sandfort, Email: ude.aibmuloc@1002sgt.

  

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Potential Clinical and Economic Value of Long-Acting Preexposure Prophylaxis for South African Women at High-Risk for HIV Infection

BACKGROUND:

For young South African women at risk for human immunodeficiency virus (HIV) infection, preexposure prophylaxis (PrEP) is one of the few effective prevention options available. Long-acting injectable PrEP, which is in development, may be associated with greater adherence, compared with that for existing standard oral PrEP formulations, but its likely clinical benefits and additional costs are unknown.

METHODS:

Using a computer simulation, we compared the following 3 PrEP strategies: no PrEP, standard PrEP (effectiveness, 62%; cost per patient, $150/year), and long-acting PrEP (effectiveness, 75%; cost per patient, $220/year) in South African women at high risk for HIV infection (incidence of HIV infection, 5%/year). We examined the sensitivity of the strategies to changes in key input parameters among several outcome measures, including deaths averted and program cost over a 5-year period; lifetime HIV infection risk, survival rate, and program cost and cost-effectiveness; and budget impact.

RESULTS:

Compared with no PrEP, standard PrEP and long-acting PrEP cost $580 and $870 more per woman, respectively, and averted 15 and 16 deaths per 1000 women at high risk for infection, respectively, over 5 years. Measured on a lifetime basis, both standard PrEP and long-acting PrEP were cost saving, compared with no PrEP. Compared with standard PrEP, long-acting PrEP was very cost-effective ($150/life-year saved) except under the most pessimistic assumptions. Over 5 years, long-acting PrEP cost $1.6 billion when provided to 50% of eligible women.

CONCLUSIONS:

Currently available standard PrEP is a cost-saving intervention whose delivery should be expanded and optimized. Long-acting PrEP will likely be a very cost-effective improvement over standard PrEP but may require novel financing mechanisms that bring short-term fiscal planning efforts into closer alignment with longer-term societal objectives.

Below:  Average discounted per-person lifetime cost distribution of the no preexposure prophylaxis (PrEP), standard PrEP (Std-PrEP), and long-acting PrEP (LA-PrEP) strategies

Below:  Cumulative discounted costs, human immunodeficiency virus (HIV)–related deaths, and women receiving antiretroviral therapy (ART) for the no preexposure prophylaxis (PrEP), standard PrEP (Std-PrEP), and long-acting PrEP (LA-PrEP) strategies.

By:   Walensky RP1, Jacobsen MM2, Bekker LG3, Parker RA4, Wood R3, Resch SC5, Horstman NK2, Freedberg KA6, Paltiel AD7.

• 1Medical Practice Evaluation Center Division of Infectious Disease Division of General Internal Medicine Division of Infectious Disease, Brigham and Women's Hospital Harvard University Center for AIDS Research, Harvard Medical School.
• 2Medical Practice Evaluation Center Division of General Internal Medicine.
• 3Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Medicine, University of Cape Town, South Africa.
• 4Medical Practice Evaluation Center Division of General Internal Medicine MGH Biostatistics Center, Massachusetts General Hospital Harvard University Center for AIDS Research, Harvard Medical School.
• 5Center for Health Decision Science.
• 6Medical Practice Evaluation Center Division of Infectious Disease Division of General Internal Medicine Harvard University Center for AIDS Research, Harvard Medical School Department of Health Policy and Management, Harvard T. H. Chan School of Public Health Department of Epidemiology, Boston University School of Public Health, Massachusetts.
• 7Yale School of Public Health, New Haven, Connecticut. 

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New HIV Infections among Women (15–24 years old) in South Africa, 2014

Via:   http://ht.ly/V7ouT  By:  https://twitter.com/unaids

Full slide deck:  http://goo.gl/uS2HNO

Motherhood and the "Madness of Hunger": "…Want Almal Vra vir My vir 'n Stukkie Brood" ("…Because Everyone Asks Me for a Little Piece of Bread")

It is widely assumed that the social and economic conditions of poverty can be linked to common mental disorders in low-, middle- and high-income countries. Despite the considerable increase in quantitative studies investigating the link between poverty and mental health, the nature of the connection between poverty and emotional well-being/distress is still not fully comprehended. 

In this qualitative study, exploring how one group of Coloured South African women, diagnosed with depression and residing in a semi-rural low-income South African community, subjectively understand and experience their emotional distress, data was collected by means of in-depth semi-structured interviews and social constructionist grounded theory was used to analyse the data. 

We will attempt to show

1. that the depressed women in this group of respondents frequently refer to the emotional distress caused by hungry children and 
2. that the emotional distress described by the respondents included emotions typically associated with depression (such as sadness, hopelessness and guilt), but also included emotions not necessarily associated with depression (such as anxiety, anger and anomie). 

In our attempt to understand (both psychologically and politically) the complex emotional response of mothers to their children's hunger, we argue that powerful gender and neo-liberal discourses within which mothers are interpellated to care for children, and more specifically, to make sure that children are not hungry, mean that the mothers of hungry children felt that they were not fulfilling their responsibilities and thus felt guilty and ashamed. 

This shame seemed, in turn, to lead to anger and/or anomie, informing acting out behaviours ranging from verbal and physical aggression to passive withdrawal. 

A vicious cycle of hunger, sadness and anxiety, shame, anger and anomie, aggression and withdrawal, negative judgement, and more shame, are thus maintained. As such, the unbearable rebukes of hungry children can be thought of as evoking a kind of "madness" in low-income mothers.

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By: Kruger LM1, Lourens M2.

• 1Department of Psychology, Stellenbosch University, Private Bag X1, Matieland, 7602, South Africa. lkrug@sun.ac.za.
• 2Clinical Psychology, Department of Psychology, Stellenbosch University, 1 Whitnall Street, Grahamstown, 6139, South Africa. lourens.marleen@gmail.com. 

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Human Papillomavirus Prevalence in South African Women & Men According to Age & Human Immunodeficiency Virus Status

Both cervical cancer and human immunodeficiency virus (HIV) are major public health problems in Sub-Saharan Africa. The objectives of the study were to investigate human papillomavirus (HPV) prevalence according to age, HIV status and gender.

Participants were 208 HIV-negative women, 278 HIV-positive women, 325 HIV-negative men and 161 HIV-positive men between the ages of 18–66 years. HPV types were determined in cervical and penile cells by Roche Linear Array HPV genotyping assay.

HPV prevalence was 36.7 % (76/207; 95 % confidence intervals (CI): 30.4–43.4 %) in HIV-negative women, with the highest prevalence of 61.0 % (25/41; 95 % CI: 45.7–74.4 %) in women aged 18–25 years. HPV prevalence was 74.0 % (205/277; 95 % CI: 68.5–78.8 %) in HIV-positive women, with the highest prevalence of 86.4 % (38/44; 95 % CI: 72.9–94.0 %) in women aged 18–25 years. HPV prevalence was found to decrease with increasing age in HIV-negative women (P = 0.0007), but not in HIV-positive women (P = 0.898). HPV prevalence was 50.8 % (159/313; 95 % CI: 45.3–56.3 %) in HIV-negative men, with the highest prevalence of 77.0 % (27/35; 95 % CI: 60.7–88.2 %) in men aged 18–25 years. HPV prevalence was 76.6 % (121/158; 95 % CI: 69.2–82.9 %) in HIV-positive men, with the highest prevalence of 87.5 % (7/8; 95 % CI: 50.8–99.9 %) in men 18–25 years of age. HPV prevalence was found to decrease with increasing age in HIV-negative men (P = 0.004), but not in HIV-positive men (P = 0.385). HIV-positive women had a significantly higher prevalence of one or more HPV type(s) in the bivalent (HPV-16/18: 20 % 55/277, 9 % 12/207; P <0.001), quadrivalent (HPV-6/11/16/18: 26 % 71/277, 12 % 24/207; P = 0.001) and nonavalent vaccine (HPV-6/11/16/18/31/33/52/56/58: 65 % 181/277, 24 % 50/207; P<0.001) compared to HIV-negative women. Similar observation were observed in men for bivalent (20 % 32/158, 10 % 30/313; P = 0.001), quadrivalent (35 % 56/158, 13 % 41/313; P <0.001) and nonavalent vaccine (75 % 119/158, 28 % 87/313; P <0.001).

This study demonstrated high HPV prevalence among HIV-positive women and men in all age groups. The high prevalence of HPV types found in bivalent, quadrivalent and nonavalent vaccines in South African HIV-positive and HIV-negative women and men demonstrate that this population will greatly benefit from current HPV vaccines.

Below: Distribution of multiple HPV genotype infections in HIV-positive (a) and HIV-negative (b) women

Below: Distribution of multiple HPV genotype infections in HIV-positive (a) and HIV-negative (b) men

Below: Prevalence of types targeted by bivalent, quadrivalent and nonavalent HPV vaccines in women and men according to HIV status

Full article at: http://goo.gl/8sZj10

By: Zizipho Z A Mbulawa¹², David Coetzee³ and Anna-Lise Williamson^145*

¹Institute of Infectious Disease and Molecular Medicine and Division of Medical Virology, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa

²Center for HIV and STIs, National Institute for Communicable Disease, National Health Laboratory Service, Cape Town, South Africa

³Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

⁴SAMRC Gynaecological Cancer Centre, University of Cape Town, Cape Town, South Africa

⁵National Health Laboratory Service, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa

   

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