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C-Channel Issue 18

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Depending on your geographical location, visit Developing World or Industrialized World.
C-Channel header  March 2010

Dear Colleagues,

C-Channel 18 highlights HIV prevention and SBCC. Three articles explore HIV prevention in the context of gender equity and heterosexual relationships. Five articles look at HIV and the underserved population of men who have sex with men (MSM). One article explores HIV and multiple concurrent partnerships (MCP). The final two articles are on malaria prevention during pregnancy.

C-Change used its Social and Behavior Change Communication (SBCC) Learning Package to conduct a 10-day SBCC training for Southern African AIDS Trust (SAT) in January-February 2010 and to further strengthen SAT’s organizational and programming capacity in SBCC.

C-Change has implemented an innovative community dialogue intervention in Lesotho that addresses MCP, a significant driver of HIV. See the C-Change website for further information on implementation, capacity strengthening, and research activities.

Thank you,
The Knowledge Management Team at C-Change


To view archived issues, visit www.c-changeprogram.org/c-channel


HIV AND GENDER

1. Gender & sexuality: Emerging perspectives from the heterosexual epidemic in South Africa & implications for HIV risk and prevention
FREE FULL TEXT

2. Integrating HIV prevention into services for abused women in South Africa

3. Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa

HIV AND MSM

4. HIV prevalence, risks for HIV infection, and human rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana
FREE FULL TEXT

5. Breaking the silence: South African HIV policies and the needs of men who have sex with men

6. HIV and related risk behavior among men who have sex with men in Zanzibar, Tanzania: Results of a behavioral surveillance survey

7. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil
FREE FULL TEXT

HIV AND MCP

8. Sexual networks and social capital: Multiple and concurrent sexual partnerships as a rational response to unstable social networks

MALARIA PREVENTION AND PREGNANCY

9. Rural Gambian women's reliance on health workers to deliver sulphadoxine-pyrimethamine as recommended intermittent preventive treatment for malaria in pregnancy
FREE FULL TEXT

10. Community-based distribution of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy improved coverage but reduced antenatal attendance in southern Malawi
FREE FULL TEXT

OTHER RESOURCES

ART and risk of heterosexual HIV-1 transmission in HIV-1 serodiscordant African couples: A multinational prospective study
Click here to access the abstract online


The African Network for Strategic Communication in Health and Development (AfriComNet) announces the 2010 call for nominations for the fourth Annual Award for Excellence in HIV and AIDS Communication in Africa.

Deadline for nominations is 15 March 2010.
For additional information: http://www.africomnet.org/events/awards/2010/nommination2010.php


HIV AND GENDER

1. Gender & sexuality: Emerging perspectives from the heterosexual epidemic in South Africa & implications for HIV risk and prevention  

Authors: Jewkes R 1; Morrell R 2
Institutions: 1 Gender & Health Research Unit, Medical Research Council, Pretoria, South Africa; 2 Research Office, University of Cape Town, Rondebosch, South Africa
Source: Journal of the International AIDS Society 9 Feb 2010; doi:10.1186/1758-2652-13-6. [Epub before print]

ABSTRACT

Research shows that gender power inequity in relationships and intimate partner violence places women at enhanced risk of HIV infection. Men who have been violent towards their partners are more likely to have HIV. Men's behaviours show a clustering of violent and risky sexual practices, suggesting important connections. This paper draws on Connell's notion of hegemonic masculinity and reflections on emphasised femininities to argue that these sexual, and male violent, practices are rooted in and flow from cultural ideals of gender identities. The latter enable us to understand why men and women behave as they do, and the emotional and material context within which sexual behaviours are enacted. In South Africa, whilst gender identities show diversity, the dominant ideal of Black African manhood emphasises toughness, strength and expression of prodigious sexual success. It is a masculinity women desire, yet it is sexually risky and a barrier to men engaging with HIV treatment. Hegemonically masculine men are expected to be in control of women, and violence may be used to establish this control. Instead of resisting this, the dominant ideal of femininity embraces compliance and tolerance of violent and hurtful behaviour, including infidelity. The women partners of hegemonically masculine men are at risk of HIV because they lack control of the circumstances of sex during particularly risky encounters. They often present their acquiescence to their partner's behaviour as a trade off made to secure social or material rewards, for this ideal of femininity is upheld, not by violence per se, by a cultural system of sanctions and rewards. Thus men and women who adopt these gender identities are following ideals with deep roots in social and cultural processes, and thus they are models of behaviour that may be hard for individuals to critique and in which to exercise choice. Women who are materially and emotionally vulnerable are least able to risk experiencing sanctions or foregoing these rewards and thus are most vulnerable to their men folk. We argue that the goals of HIV prevention and optimising of care can best be achieved through change in gender identities, rather than a focus on individual sexual behaviours.

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2. Integrating HIV prevention into services for abused women in South Africa

Authors: Sikkema KJ 1; Neufeld SA 2,3; Hansen NB 2; Mohlahlane R 4; Van Rensburg MJ 5; Watt MH 6; Fox AM 7; Crewe M 4
Institutions: 1 Department of Psychology and Neuroscience, Duke University, Durham, NC; 2 School of Medicine, Yale University, New Haven, CT; 3 Department of Social and Developmental Psychology, University of Cambridge, Cambridge, UK; 4 Centre for the Study of AIDS, University of Pretoria, Pretoria, South Africa; 5 People Opposing Women Abuse, Johannesburg, South Africa; 6 Global Health Institute, Duke University, Durham, NC; 7 Mailman School of Public Health, Columbia University, New York, NY
Source: AIDS & Behavior 14 Oct 2009; doi 10.1007/s10461-009-9620-4. [Epub ahead of print]

ABSTRACT

The relationship between intimate partner violence (IPV) and HIV risk is well documented, but few interventions jointly address these problems. We developed and examined the feasibility of an intervention to reduce HIV risk behaviors among 97 women seeking services for IPV from a community-based NGO in Johannesburg, South Africa. Two versions of the intervention (a 6-session group and a 1-day workshop) were implemented, both focusing on HIV prevention strategies integrated with issues of gender and power imbalance. Attendance was excellent in both intervention groups. Assessments were conducted at baseline, post-intervention and two-month follow-up to demonstrate the feasibility of an intervention trial. Women in both groups reported reductions in HIV misperceptions and trauma symptoms, and increases in HIV knowledge, risk reduction intentions, and condom use self-efficacy. The 6-session group showed greater improvements in HIV knowledge and decreases in HIV misperceptions in comparison to the 1-day workshop. The study demonstrated the feasibility and potential benefit of providing HIV prevention intervention to women seeking assistance for IPV.

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3. Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa

Authors: Desgrées-du-Loû A a; Orne-Gliemann J b
Institutions: a Institut de Recherche pour le Développement, Centre Population Développement (CEPED), Paris, France; b Institut de Santé Publique Epidémiologie Développement, Université Victor Segalen Bordeaux 2, Bordeaux, France
Source Reproductive Health Matters Nov 2008; 16(32): 151-61.

ABSTRACT

In Africa, a large proportion of HIV infections occur within stable relationships, either because of prior infection of one of the partners or because of infidelity. In five African countries at least two-thirds of couples with at least one HIV-positive partner were HIV serodiscordant; in half of them, the woman was the HIV-positive partner. Hence, there is an urgent need to define strategies to prevent HIV transmission within couple relationships. HIV counselling and testing have largely been organised on an individual and sex-specific basis, for pregnant women in programmes for prevention of mother-to-child transmission of HIV and in STI consultations and recently male circumcision for men. A couple-centred approach to HIV counselling and testing would facilitate communication about HIV status and adoption of preventive behaviours within couples. This paper reviews what is known about HIV serodiscordance in heterosexual couples in sub-Saharan Africa and what has been published about couple-centred initiatives for HIV counselling and testing since the early 1990s. Despite positive outcomes, couple-oriented programmes have not been implemented on a large scale. In order to stimulate and strengthen HIV prevention efforts, increased attention is required to promote prevention and testing and counselling for couples in stable relationships.

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HIV AND MSM

4. HIV prevalence, risks for HIV infection, and human rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana

Authors: Baral S 1,7; Trapence G 2; Motimedi F 3; Umar E 4; Iipinge S 5; Dausab F 6; Beyrer C 1
Institutions: 1 Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD; 2 Center for the Development of People, Blantyre, Malawi 3 Botswana Network on Ethics, Law, and HIV/AIDS, Gaborone, Botswana; 4 Department of Community Health, University of Malawi, College of Medicine, Blantyre, Malawi; 5 HIV/AIDS Coordinator, University of Namibia, Windhoek, Namibia; 6 The Rainbow Project, Windhoek, Namibia; 7 Department of Public Health Sciences, University of Toronto, Toronto, Ontario, Canada
Source: PLoS One 26 Mar 2009; 4(3): e4997.

ABSTRACT

BACKGROUND: In the generalized epidemics of HIV in southern Sub-Saharan Africa, men who have sex with men have been largely excluded from HIV surveillance and research. Epidemiologic data for MSM in southern Africa are among the sparsest globally, and HIV risk among these men has yet to be characterized in the majority of countries.

METHODOLOGY: A cross-sectional anonymous probe of 537 men recruited with non-probability sampling among men who reported ever having had sex with another man in Malawi, Namibia, and Botswana using a structured survey instrument and HIV screening with the OraQuick(c) rapid test kit.

PRINCIPAL FINDINGS: The HIV prevalence among those between the ages of 18 and 23 was 8.3% (20/241); 20.0% (42/210) among those 24-29; and 35.7% (30/84) among those older than 30 for an overall prevalence of 17.4% (95% CI 14.4-20.8). In multivariate logistic regressions, being older than 25 (aOR 4.0, 95% CI 2.0-8.0), and not always wearing condoms during sex (aOR 2.6, 95% CI 1.3-4.9) were significantly associated with being HIV-positive. Sexual concurrency was common with 16.6% having ongoing concurrent stable relationships with a man and a woman and 53.7% had both male and female sexual partners in proceeding 6 months. Unprotected anal intercourse was common and the use of petroleum-based lubricants was also common when using condoms. Human rights abuses, including blackmail and denial of housing and health care was prevalent with 42.1% (222/527) reporting at least one abuse.

CONCLUSIONS: MSM are a high-risk group for HIV infection and human rights abuses in Malawi, Namibia, and Botswana. Concurrency of sexual partnerships with partners of both genders may play important roles in HIV spread in these populations. Further epidemiologic and evaluative research is needed to assess the contribution of MSM to southern Africa's HIV epidemics and how best to mitigate this. These countries should initiate and adequately fund evidence-based and targeted HIV prevention programs for MSM.

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5. Breaking the silence: South African HIV policies and the needs of men who have sex with men

Authors: Rispel LC a; Metcalf CA b
Institutions: a Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; b Social Aspects of HIV/AIDS and Health Research Programme, Human Sciences Research Council, Cape Town, South Africa
Source: Reproductive Health Matters May 2009; 17(33): 133-42.

ABSTRACT

Although the HIV epidemic among men who have sex with men (MSM) in South Africa preceded the onset of the generalised HIV epidemic by several years, current policies and programmes focus on heterosexual transmission and mother-to-child transmission. We used an adaptation of the UNAIDS Country Harmonised Alignment Tool (CHAT) to assess whether existing HIV policies and programmes in South Africa address the needs of MSM. This covered mapping of key risk factors and epidemiology of HIV among MSM; participation of MSM in the HIV response; and an enabling environment for service provision, funding and human resources. We found that current policies and programmes are unresponsive to the needs of MSM and that epidemiologic information is lacking, in spite of policy on MSM in the National Strategic Plan. We recommend that government initiate sentinel surveillance to determine HIV prevalence among MSM, social science research on the contexts of HIV transmission among MSM, and appropriate HIV prevention and care strategies. MSM should be closely involved in the design of policies and programmes. Supportive programme development should include dedicated financial and human resources, appropriate guidelines, and improved access to and coverage of HIV prevention, treatment and care services for MSM.

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6. HIV and related risk behavior among men who have sex with men in Zanzibar, Tanzania: Results of a behavioral surveillance survey

Authors: Dahoma M 1; Johnston LG 2; Holman A 3; Miller LA 2; Mussa M 1; Othman A 1; Khatib A 1; Issa R 1; Kendall C 2; Kim AA 4,5
Institutions: 1 Zanzibar AIDS Control Programme, Ministry of Health and Social Welfare, Zanzibar, Tanzania; 2 Tulane University School of Public Health and Tropical Medicine, Department of International Health & Development, Center for Global Health Equity, New Orleans, LA; 3 Association of Schools of Public Health/HHS-Centers for Disease Control and Prevention/Global AIDS Program, Dar Es Salaam, Tanzania; 4 HHS-Centers for Disease Control and Prevention/Global AIDS Program, Atlanta, GA; 5 Division of Viral and Rickettsial Diseases, Centers for Disease Control and Prevention, Atlanta, GA
Source: AIDS & Behavior 8 Dec 2009; doi: 10.1007/s10461-009-9646-7. [Epub ahead of print]

ABSTRACT

We conducted a respondent driven sampling survey to estimate HIV prevalence and risk behavior among men who have sex with men (MSM) in Unguja, Zanzibar. Men aged ≥15 years living in Unguja and reporting anal sex with another man in the past 3 months were asked to complete a questionnaire and provide specimens for biologic testing. HIV prevalence was 12.3% (95% confidence interval 8.7, 16.3). HIV infection was associated with injecting drugs in the past 3 months, Hepatitis C virus infection and being paid for sex in the past year. Interventions for MSM in Zanzibar are needed and should include linkages to prevention, care and treatment services.

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7. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil

Authors: Tun W 1; de Mello M 2; Pinho A 3; Chinaglia M 4; Diaz J 4
Institutions: 1 Population Council, Washington DC; 2 ICICT, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil; 3 Graduate Program in Epidemiology, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil; 4 Reprolatina, Campinas, São Paulo, Brazil
Source: Sexually Transmitted Infections Nov 2008; 84(6): 455-7.

ABSTRACT

OBJECTIVES: To compare population-based prevalence estimates of sexual risk behaviours and HIV seroprevalence of male sex workers who have sex with men (MSM) and those not engaged in sex work in Campinas, Brazil.

METHODS: MSM (n = 658) were recruited for a cross-sectional study through respondent-driven sampling. Audio-assisted computer self-interview was used to collect information on sexual behaviours and HIV testing (optional) was performed. Population-based prevalence estimates with 95% CI of characteristics and behaviours of MSM sex workers and non-sex workers are reported.

RESULTS: One-quarter reported ever receiving payment for sex and 14.8% (95% CI 11.1 to 19.0) had been paid in the previous 2 months; most exclusively with men. MSM sex workers were significantly more likely than non-sex workers to report being transgendered (40.5% vs 8.1%), to practise unprotected receptive (22.4% vs 4.6%) and insertive (20.5% vs 5.0%) anal intercourse with > or =2 male partners and to have unprotected vaginal sex with women (22.7% vs 5.6%). MSM sex workers experienced significantly greater rates of psychological abuse (80.9% vs 58.4%) and physical abuse (48.2% vs 15.2%).

CONCLUSIONS: MSM sex workers have higher sexual risk behaviours as well as social vulnerabilities than the general population of MSM. HIV/sexually transmitted infection prevention efforts should be targeted to this riskier subgroup. Programmes should be transgender sensitive, should recognise that MSM sex workers have sex with men and women and address other factors that influence risk, such as homophobic abuse.

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HIV AND MCP

8. Sexual networks and social capital: Multiple and concurrent sexual partnerships as a rational response to unstable social networks

Author: Robert Thornton
Source: African Journal of AIDS Research Oct 2009; 8(4): 413–421.
http://ajol.info/index.php/ajar

ABSTRACT

Multiple and concurrent sexual partnerships (MCP) are prevalent in southern Africa and have been identified as a primary cause of high HIV prevalence in this region. Sexual liaisons with multiple partners serve to increase the size and diversity of an individual's sexual — and social — network and therefore to increase their social capital. This maximisation of social capital may minimise the risk to relationship(s) at the cost of maximising the biological risk of HIV infection. Many sexually active individuals appear to neglect their biological risk of HIV infection in order to maximise their 'social capital.' This would seem to be irrational from the perspective of any individual actor, but on a larger social scale, this may give individuals better access to some social and economic goods. The article argues that people who are in unstable and less-connected parts of the sexual network are those most active in building their sexual networks, even where they are not especially promiscuous. However, such strategies may increase exposure to HIV infection in particular populations, such as intravenous drug users, sex workers, and men having sex with men, as well as in the general population of heterosexual southern Africans. What these high HIV-prevalence populations have in common is their participation in sexual–social networks in which individuals try to maximise their social capital by extending the diversity and density of their sexual networks. The discussion shifts analytic attention away from the notion of higher-risk sexual practices of individuals towards consideration for the structure and dynamics of social and sexual networks at a societal level.

Keywords: HIV/AIDS; HIV transmission; risk behaviour; risk perceptions; sexual behaviour; social behaviour; South Africa

This article is used with permission of the publisher (NISC (Pty) Ltd).

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MALARIA PREVENTION AND PREGNANCY

9. Rural Gambian women's reliance on health workers to deliver sulphadoxine-pyrimethamine as recommended intermittent preventive treatment for malaria in pregnancy

Authors: Brabin L 1; Stokes E 1; Dumbaya I 2; Owens S 2
Institutions: 1 Academic Unit of Obstetrics & Gynaecology, University of Manchester, Manchester, UK; 2 Medical Research Council, Keneba Field Station, Keneba, the Gambia
Source: Malaria Journal 12 Feb 2009; 8:25.

ABSTRACT

BACKGROUND: The use of most anti-malarial medications is restricted during pregnancy, but two doses of sulphadoxine-pyrimethamine are recommended after the first trimester as intermittent preventive treatment in pregnancy (IPTp). In The Gambia, only 32% of women receive two doses and very little research has been conducted on women's awareness of drug safety during pregnancy. The objective of this paper was to assess whether rural Gambian women were aware of the importance of the timing of the two-dose IPT dose schedule and its relevance to drug safety.

METHODS: This was a qualitative study in which 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants were conducted. A generic qualitative approach was used to generate a theory as to why women might not participate in IPTp as recommended.

RESULTS: Although most women used calendar months to count their stage of pregnancy, these months did not correlate with their concept of foetal development. Foetal growth was described following Islamic tradition as water, clot, piece of meat and human being, although there was little consensus about the order or timing in which these stages occurred. Common signs and conditions of malaria were known. Women were anxious about miscarriage and recognized that some medicines should not be taken in the first trimester, but were urged by men and traditional birth attendants to attend for antenatal care in the first trimester to "start treatment." General knowledge about the purpose of pregnancy medications and when they should be taken was poor among both men and women. One important result was that women relied entirely on health workers to provide safe drugs, at the correct time.

CONCLUSION: Women did not have relevant information to judge the safety and appropriate timing of pregnancy drugs, which made them over-reliant on health workers. They should be encouraged to date their own pregnancies in culturally relevant terms and to anticipate when and which medications they should receive.

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10. Community-based distribution of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy improved coverage but reduced antenatal attendance in southern Malawi

Authors: Msyamboza KP; Savage EJ; Kazembe PN; Gies S; Kalanda G; D'Alessandro U; Brabin BJ
Institutions: 1 Malaria Alert Centre, College of Medicine, Blantyre, Malawi; 2 Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, UK; 3 Baylor College of Medicine, Children's Clinical Centre of Excellence, Lilongwe, Malawi; 4 Epidemiology and Control of Parasitic Diseases Unit, Institute of Tropical Medicine, Antwerp, Belgium; 5 EmmaKinderziekenhuis, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; 6 Department of Community Paediatrics, Royal Liverpool Children's Hospital NHS Trust, Alder Hey, Liverpool, UK
Source: Tropical Medicine & International Health Feb 2009; 14(2): 183-9. [Epub before print]

ABSTRACT

OBJECTIVE: To evaluate the impact of a 2-year programme for community-based delivery of sulfadoxine-pyrimethamine (SP) on intermittent preventive treatment during pregnancy coverage, antenatal clinic attendance and pregnancy outcome.

METHODS: Fourteen intervention and 12 control villages in the catchment areas of Chikwawa and Ngabu Government Hospitals, southern Malawi, were selected. Village-based community health workers were trained in information, education and counselling on malaria control in pregnancy and the importance of attending antenatal clinics and promoted these messages to pregnant women. In the intervention group community health workers also distributed SP to pregnant women.

RESULTS: In the control area, coverage of intermittent preventive treatment during pregnancy (>2 doses) was low before (44.1%) and during the intervention (46.1%). In the intervention area, coverage increased from 41.5% to 82.9% (P < 0.01). Antenatal clinic attendance (>2 visits) was maintained in control villages at above 90%, but fell in intervention villages from 87.3% to 51.5% (P < 0.01). Post-natal malaria parasitaemia prevalence fell in women from both study areas during the intervention phase (P < 0.05). Increasing the coverage of intermittent preventive treatment during pregnancy to >40% did not significantly improve maternal haemoglobin or reduce low birthweight prevalence.

CONCLUSIONS: Better coverage of community-based intermittent preventive treatment during pregnancy can lower attendance at antenatal clinics; thus its effect on pregnancy outcome and antenatal attendance need to be monitored.

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