AIDSImpact special issue: pathways to transactional sex among peri-urban South African women: the role of relationship control, food insecurity and alcohol misuse.

Transactional sex increases sub-Saharan African women's risk of HIV acquisition. We quantitatively explored the pathways contributing towards women's future engagement in transactional sex with casual partners and khwapheni (secret concurrent sex partners). We conducted secondary data analysis from a cluster randomised controlled trial in urban informal settlements in eThekwini Municipality., South Africa. Data were collected at enrolment (t0) and 24 months' later (t2) using self-completed questionnaires. Structural equation modelling (SEM) assessed pathways leading to transactional sex over two years. 677 women 18-35 years were enrolled and 80.5% (n = 545) were followed up. At t2, 44.6% of respondents reported transactional sex with a casual partner or khwapheni. The SEM demonstrated a small effect (d = 0.23) between transactional sex at t0 and at t2. Controlling for past transactional sex, main partner relationship control had a large effect size on future transactional sex (d = 0.60). Hazardous drinking had a medium effect size (d = 0.45) and food insecurity a small effect (d = 0.24), (RMSEA 0.03, 90%CI 0.02-0.04; CFI 0.97; TLI 0.96). HIV prevention programming should highlight current transactional sex but also address structural issues predicting future transactional sex, including food insecurity and alcohol misuse. Gender transformative interventions to reduce controlling behaviours in main relationships are worth investigating.

Reflections on the process, challenges, and lessons learned conducting remote qualitative research on Violence against women during COVID-19 pandemic lockdown in South Africa.

BACKGROUND: Violence against women (VAW) research is a sensitive topic, which has been conducted mainly using face-to-face methods. The COVID-19 pandemic lockdown and restrictions on movement presented an opportunity to conduct VAW research using remote methods. We discuss how we adapted methods, reflect on lessons learned, and make recommendations highlighting key considerations when conducting remote research on a sensitive topic of VAW. METHODS: We designed and conducted an exploratory qualitative study using remote methods with 18 men and 19 women, aged 18 years and older, who lived with their partner or spouse during lockdown in South Africa. The aim of the study was to explore experiences of COVID-19 lockdown, and its link to women and children's experiences of violence in the homes. Data presented in this paper draws from researchers' reflections drawn from debriefing sessions during the research process, and from participants' interview transcripts. FINDINGS: Remote recruitment of participants took longer than anticipated, and we had to re-advertise the study. We could not ensure safety and privacy during interviews. Regardless of all the safety and privacy measures we put in place during the research process, some participants had an adult person present in the room during interviews, and the researchers had no control over interruptions. Rapport was difficult to establish without an in-person connection, which limited disclosure about violence experience (amongst women) and perpetration (amongst men). CONCLUSIONS: Given the methodological and ethical challenges which limited disclosure of VAW remotely, we conclude that telephone interviews used in our study impacted on the quality of study data. Therefore, we do not recommend VAW research to be conducted remotely, unless it is essential and participants are already known to the interviewer and trust has been established.

Cluster randomized controlled trial of Stepping Stones and Creating Futures to reduce mental health challenges among young men in informal settlements in KwaZulu-Natal Province, South Africa.

BACKGROUND: Informal settlements are high density areas in and around cities, characterized by a lack of formal planning and basic amenities, being known in South Africa for high levels of mental disorder driven by violence, and complex social and economic challenges. In particular, young men's poor mental health goes untreated, with relatively few evidenced-based interventions available in this setting. AIM: This cluster randomized controlled trial investigated the effectiveness of Stepping Stones and Creating Futures (SS/CF), a participatory gender transformative and economic empowerment intervention, on the mental health of young men living in South African informal settlement. METHODS: A total of 674 young men ages 18 to 30 years were recruited in 34 clusters in Durban's urban informal settlements. Clusters were randomly allocated (1:1) to either the experimental SS/CF or control arm and participants were followed-up over 24-months. Intention-to-treat analysis based on generalized estimating equations (GEE) were fitted to quantify the impact of SS/CF on the men's anxiety and post-traumatic stress (PTS) symptomatology. RESULTS: At end of the 24 months follow-period, anxiety (adjusted odds ratio [aOR]: 0.62, p = .04, 95% CI [0.39, 0.99]) and PTS (aOR = 0.52, p = .03, 95% CI [0.29, 0.93]) were significantly lower for group assigned to the SS/CF compared to the control group. CONCLUSION: SS/CF, a gender transformative and livelihoods strengthening intervention designed to address poverty and other socio-economic challenges in informal settlements reduced anxiety and PTS among men with mental health challenges living in informal settlements.

Pooled analysis of the association between food insecurity and violence against women: Evidence from low- and middle-income settings.

Background: Intimate partner violence impacts relationships across the socioeconomic spectrum, nonetheless its prevalence is reported to be highest in areas that are most socio-economically deprived. Poverty has direct and indirect impacts on intimate partner violence (IPV) risk, however, one of the postulated pathways is through food insecurity. The aim of this paper is to describe the association between food insecurity (household hunger) and women's experiences, and men's perpetration, of intimate partner violence and non-partner sexual violence in data from Africa and Asia. Methods: We conducted a pooled analysis of data from baseline interviews with men and women participating in six Violence Against Women prevention intervention evaluations and present a meta-analysis using mixed-effects Poisson regression models. Data were from South Africa (two studies), Ghana, Rwanda (two data sets), and Afghanistan and comprised interviews with 6545 adult women and 8104 adult men. We assessed food insecurity with the Household Hunger Scale. Results: Overall, 27.9% of women experienced moderate food insecurity (range from 11.1% to 44.4%), while 28.8% of women reported severe food insecurity (range from 7.1 to 54.7%). Overall food insecurity was associated with an increased likelihood of women experiencing physical intimate partner violence, adjusted incidence rate ratio (aIRR) = 1.40 (95% CI = 1.23 to 1.60) for moderate food insecurity and aIRR = 1.73 (95% CI = 1.41 to 2.12) for severe food insecurity. It was also associated with an increased likelihood of men reporting perpetration of physical IPV, with aIRR = 1.24 (95% CI = 1.11 to 1.39) for moderate food insecurity and aIRR = 1.18 (95% CI = 1.02 to 1.37) for severe food insecurity. Food insecurity was not significantly associated with women's experience of non-partner sexual violence, aIRR = 1.27 (95% CI = 0.93 to 1.74) for moderate or severe food insecurity vs none, nor men's perpetration of non-partner sexual violence aIRR = 1.02 (95% CI = 0.90 to 1.15). Conclusions: Food insecurity is associated with increased physical intimate partner violence perpetration and experience reported by men and women. It was not associated with non-partner sexual violence perpetration, although there was some evidence to suggest an elevated risk of non-partner sexual violence among food-insecure women. Prevention programming needs to embrace food insecurity as a driver of intimate partner violence perpetration, however, non-partner sexual violence prevention needs to be shaped around a separate understanding of its drivers.

Challenges and opportunities in coproduction: reflections on working with young people to develop an intervention to prevent violence in informal settlements in South Africa.

Coproduction is widely recognised as essential to the development of effective and sustainable complex health interventions. Through involving potential end users in the design of interventions, coproduction provides a means of challenging power relations and ensuring the intervention being implemented accurately reflects lived experiences. Yet, how do we ensure that coproduction delivers on this promise? What methods or techniques can we use to challenge power relations and ensure interventions are both more effective and sustainable in the longer term? To answer these questions, we openly reflect on the coproduction process used as part of Siyaphambili Youth ('Youth Moving Forward'), a 3-year project to create an intervention to address the social contextual factors that create syndemics of health risks for young people living in informal settlements in KwaZulu-Natal province in South Africa. We identify four methods or techniques that may help improve the methodological practice of coproduction: (1) building trust through small group work with similar individuals, opportunities for distance from the research topic and mutual exchanges about lived experiences; (2) strengthening research capacity by involving end users in the interpretation of data and explaining research concepts in a way that is meaningful to them; (3) embracing conflicts that arise between researchers' perspectives and those of people with lived experiences; and (4) challenging research epistemologies through creating spaces for constant reflection by the research team. These methods are not a magic chalice of codeveloping complex health interventions, but rather an invitation for a wider conversation that moves beyond a set of principles to interrogate what works in coproduction practice. In order to move the conversation forward, we suggest that coproduction needs to be seen as its own complex intervention, with research teams as potential beneficiaries.

Adaptation and pre-test of a shortened Stepping Stones and Creating Futures intervention focused on HIV for young men in rural South Africa.

Men's engagement in HIV prevention and treatment is suboptimal, including in South Africa. We sought to address this through adapting an evidence-based intervention, Stepping Stones and Creating Futures (SSCF), to strengthen its HIV content and provide a more scalable (shorter) intervention in rural South Africa. We then conducted a mixed methods pre-test of the intervention among young men aged 18-35 years. To adapt SSCF, we reviewed the current evidence base and worked with male Peer Navigators to update the SSCF theory of change (ToC) and manual. The revised intervention was ~45 hours (9 sessions) as opposed to ~63 hours and included a greater focus on HIV prevention and treatment technologies. Overall, 64% (n = 60) of men approached agreed to participate in the intervention, uptake (attending one session) among those who agreed was n = 35(58%) and retention (attending 6 or more sessions) was n = 25(71%). Qualitative data emphasized the intervention was acceptable, with young men describing it as something they liked. The qualitative data also broadly supported the intervention ToC, including the normalization of HIV in men's lives, and the importance of health for men in achieving their life goals. However, it also highlighted the need to focus more on HIV-related stigma and fear, and the importance of HIV self-testing kits in encouraging testing. We revised the ToC and manual in light of this data. The adapted SSCF is acceptable and supports the ToC. Next steps is an evaluation to look at effectiveness of the intervention.

Pooled analysis of the association between mental health and violence against women: evidence from five settings in the Global South.

OBJECTIVES: To describe associations between men's poor mental health (depressive and post-traumatic stress symptomatology) and their perpetration of intimate partner violence (IPV) and non-partner sexual violence (NPSV), and women's mental health and their experiences of IPV and NPSV in five settings in the Global South. DESIGN: A pooled analysis of data from baseline interviews with men and women participating in five violence against women and girls prevention intervention evaluations. SETTING: Three sub-Saharan African countries (South Africa, Ghana and Rwanda), and one Middle Eastern country, the occupied Palestinian territories. PARTICIPANTS: 7021 men and 4525 women 18+ years old from a mix of self-selecting and randomly selected household surveys. MAIN OUTCOME MEASURES: All studies measured depression symptomatology using the Centre for Epidemiological Studies-Depression, and the Harvard Trauma Scale for post-traumatic stress disorder (PTSD) symptoms among men and women. IPV and NPSV were measured using items from modified WHO women's health and domestic violence and a UN multicountry study to assess perpetration among men, and experience among women. FINDINGS: Overall men's poor mental health was associated with increased odds of perpetrating physical IPV and NPSV. Specifically, men who had more depressive symptoms had increased odds of reporting IPV (adjusted OR (aOR)=2.13; 95%CI 1.58 to 2.87) and NPSV (aOR=1.62; 95% CI 0.97 to 2.71) perpetration compared with those with fewer symptoms. Men reporting PTSD had higher odds of reporting IPV (aOR=1.87; 95% CI 1.44 to 2.43) and NPSV (aOR=2.13; 95% CI 1.49 to 3.05) perpetration compared with those without PTSD. Women who had experienced IPV (aOR=2.53; 95% CI 2.18 to 2.94) and NPSV (aOR=2.65; 95% CI 2.02 to 3.46) had increased odds of experiencing depressive symptoms compared with those who had not. CONCLUSIONS: Interventions aimed at preventing IPV and NPSV perpetration and experience must account for the mental health of men as a risk factor, and women's experience.

Assessing the role of depression in reducing intimate partner violence perpetration among young men living in urban informal settlements using a mediation analysis of the Stepping Stones and Creating Futures intervention.

BACKGROUND: Stepping Stones and Creating Futures (SS/CF) is a gender transformative and economic empowerment intervention that has effectively reduced the perpetration of intimate partner violence (IPV) by young men living in informal settlements in South Africa. OBJECTIVE: This study examines whether depression mediated the association between SS/CF intervention and decreased IPV. METHOD: Data from a two-arm cluster randomised community-based controlled trial that evaluated the effectiveness of SS/CF in lowering IPV were obtained from 674 young men aged 18-30 within urban informal settlements in South Africa. After being randomly assigned to either the experimental arm (SS/CF) or the control arm, the participants were followed up for 24 months. Logistic regression using mediation analysis was conducted to see whether changes in depressive symptoms mediated the association between the intervention and reduced IPV perpetration. RESULTS: Findings from the mediation analysis indicated that those assigned to the SS/CF experimental group reported lower depression (ß = -0.42, p < 0.05) at 12 months, and this was subsequently associated with reduced IPV (ß = 0.43, p < 0.05) at 24 months. The direct path from SS/CF to IPV was originally (ß = -0.46, p < 0.01), but reduced in the mediation model to (ß = -0.13, p = 0.50). Depressive symptoms mediated the association between the SS/CF intervention and decreased IPV perpetration. CONCLUSION: These findings suggest that one pathway through which SS/CF decreased IPV was through improvement in mental health (i.e. depression). Future IPV prevention interventions may consider incorporating components that focus on improving mental health as a way of also reducing IPV perpetration in disadvantaged settings.

"I Carry the Trauma and Can Vividly Remember": Mental Health Impacts of the COVID-19 Pandemic on Frontline Health Care Workers in South Africa.

We know from research that pandemics and disease outbreaks expose HCWs to an increased risk of short and long-term psychosocial and occupational impacts. We conducted qualitative research among 44 frontline health care workers (FHCWs) practicing in seven South African hospitals and clinics. FHCWs were interviewed on their experiences of working during the first-wave of the COVID-19 pandemic and its perceived impact on their wellness. In this study, FHCWs included the non-medical and medical professionals in direct contact with COVID-19 patients, providing health care and treatment services during the COVID-19 pandemic. Most of the FHCWs reported stressful and traumatic experiences relating to being exposed to a deadly virus and working in an emotionally taxing environment. They reported depression, anxiety, traumatic stress symptoms, demoralization, sleep difficulties, poor functioning, increased irritability and fear of being infected or dying from COVID-19. The mental health impacts of COVID-19 on HCWs were also associated with increased poor physical wellbeing, including fatigue, burnout, headache, and chest-pains. FHCWs reported professional commitment and their faith as critical intrinsic motivators that fostered adaptive coping while working on the frontline during the first-wave of the COVID-19 pandemic. Many alluded to gaps in workplace psychosocial support which they perceived as crucial for coping mentally. The findings point to a need to prioritize interventions to promote mental wellness among FHCWs to ensure the delivery of quality healthcare to patients during pandemics or deadly disease outbreaks.

Assessing risk factors and health impacts across different forms of exchange sex among young women in informal settlements in South Africa: A cross-sectional study.

For women in South Africa, engaging in exchange sex, including transactional sex (TS), or sex work (SW), is associated with several shared poor health outcomes; yet the practices themselves differ in meaningful ways. SW is a form of commodity exchange, while TS is grounded in gendered relationship expectations of male provision and aspects of emotional intimacy. Additionally, exchange sex types could be imagined on a "continuum of instrumentality" from relationships that do not include material support; to those characterized, but not driven by support; to those primarily motivated by material support. We use cross-sectional data from 644 women ages 18-30 enrolled in a trial addressing intimate partner violence in urban KwaZulu-Natal, South Africa to assess whether these conceptualizations may also map onto different types or levels of risk. Using self-reports, we developed four exchange sex relationship categories corresponding to a continuum of instrumentality: no exchange-based relationship; TS with a main partner only; TS with a casual partner; and SW. Using tests of association and adjusted logistic regression models, we compared socio-economic and behavioural risk factors, and health outcomes across reported forms of exchange sex. We find little difference between women who report no exchange sex and those who report TS only with a main partner. By contrast, as compared to women not in exchange sex, women in casual TS and SW were poorer, and significantly more likely to report problematic alcohol use, past drug use, prior non-partner sexual violence, and PTSD; with aOR higher for women in SW for many outcomes. When comparing casual TS to SW, we find women in SW held more gender equitable attitudes and were more likely to report modern contraceptive use. We discuss the implications for distinguishing between TS and SW, and use of the continuum of instrumentality conceptualization for research and programming.

Is hope associated with HIV-acquisition risk and intimate partner violence amongst young women and men? A cross-sectional study in urban informal settlements in South Africa.

Hope is a concept that may mediate between the structural constraints people live under and their HIV-acquisition risk behaviours/experiences. Drawing on data collected as the baseline for an intervention trial between September 2015 and September 2016, among young (18-30-year-old), out-of-school women and men in urban informal settlements in Durban, South Africa, we assess whether hope, assessed by the Snyder Hope Scale, is associated with HIV-risk behaviours/experiences. 677 women (35.5%; 33.7%; 30.9%; low, medium, and high hope scores respectively) and 668 men (40.6%; 32.8%; 26.7%; low, medium, and high hope scores respectively) were included. Among women, adjusted analyses showed high levels of hope, compared to low levels, were associated with greater modern contraceptive use (aOR1.57, 1.04-2.37). For men, medium or high levels of hope, compared to low levels, were associated with reduced physical and/or sexual IPV perpetration (med: aOR0.55, 0.38-0.81, high: 0.38, 0.25-0.57), emotional IPV perpetration (med: aOR0.54, 0.36-0.80, high: aOR0.62, 0.41-0.94) and transactional sex (med: 0.57, 0.38-0.84, high: aOR0.57, 0.39-0.86) respectively. For men, hope potentially captured a pathway between an individual's structural context and their HIV-risk behaviour. Yet this was not the case for women. It may be the Snyder Hope Scale does not adequately capture localised meanings of hope.

A Prospective Analysis of the Interrelationship between Physical Intimate Partner Violence and Alcohol Use: A Post-Hoc Analysis of Young Women Involved in the Stepping Stones and Creating Futures Trial in South Africa.

Prospective studies assessing women's experience of intimate partner violence (IPV) and alcohol use have shown mixed results and all are from high-income countries. Using longitudinal data from young women in South Africa we assess whether changes in physical IPV impact alcohol use, and whether changes in alcohol use impact physical IPV experience. Post-hoc analysis of women aged 18-30 living in informal settlements in eThekwini Municipality, South Africa, involved in the Stepping Stones and Creating Futures trial, between September 2015 and October 2019, with data collected at baseline (n = 677) and endline at 24 months (n = 545, 80.5% retention). At both timepoints, women were asked about their past year physical IPV experience and alcohol use. We estimated changes in physical IPV over time and whether this was associated with harmful alcohol use at endline. We then estimated changes in alcohol use over time, and whether this was associated with experience of past year physical IPV at endline. Women who experienced an increase in physical IPV over the study period were more likely to report harmful drinking at 24 months (aOR2.45, 95% CI 1.21-4.97). Similarly, women reporting increased alcohol use over time were more likely to report past year physical IPV at 24 months (aOR2.04, 95% CI 1.21-3.46). Among young women living in urban poverty those who experienced increasing physical violence from intimate partners were more likely to report increased and problematic alcohol use. Similarly, women reporting increasing alcohol use over 24 months were more likely to report physical IPV. However, there was no evidence that decreased alcohol use led to reductions in IPV, or that reduced IPV experience led to decreased alcohol use. Future research and interventions need to consider the reciprocal risks of physical IPV and alcohol use, with a focus on joint underlying drivers.

High-Risk Contexts for Violence Against Women: Using Latent Class Analysis to Understand Structural and Contextual Drivers of Intimate Partner Violence at the National Level.

Introduction: Intimate partner violence (IPV) affects 1 in 3 women and poses a major human rights threat and public health burden, yet there is great variation in risk globally. Whilst individual risk factors are well-studied, less research has focussed on the structural and contextual drivers of IPV and how these co-occur to create contexts of high risk. Methods: We compiled IPV drivers from freely-accessible global country-level data sources and combined gender inequality, natural disasters, conflict, colonialism, socioeconomic development and inequality, homicide and social discrimination in a latent class analysis, and identified underlying 'risk contexts' based on fit statistics and theoretical plausibility (N=5,732 country-years; 190 countries). We used multinomial regression to compare risk contexts according to: proportion of population with disability, HIV/AIDS, refugee status, and mental health disorders; proportion of men with drug use disorders; men's alcohol consumption; and population median age (N=1,654-5,725 country-years). Finally, we compared prevalence of physical and/or sexual IPV experienced by women in the past 12 months across risk contexts (N=3,175 country-years). Results: Three distinct risk contexts were identified: 1) non-patriarchal egalitarian, low rates of homicide; 2) patriarchal post-colonial, high rates of homicide; 3) patriarchal post-colonial conflict and disaster-affected. Compared to non-patriarchal egalitarian contexts, patriarchal post-colonial contexts had a younger age distribution and a higher prevalence of drug use disorders, but a lower prevalence of mental health disorders and a smaller refugee population. IPV risk was highest in the two patriarchal post-colonial contexts and associated with country income classification. Conclusions: Whilst our findings support the importance of gender norms in shaping women's risk of experiencing IPV, they also point towards an association with a history of colonialism. To effectively address IPV for women in high prevalence contexts, structural interventions and policies are needed that address not only gender norms, but also broader structural inequalities arising from colonialism.

High levels of poor mental health among young men in urban informal settlements in South Africa: a community-based study of social determinants.

Informal settlements (high population density areas at the outskirts of urban areas characterized by lack basic amenities) in South Africa are consequences of apartheid regime's discriminatory migrant labour and spatial policy and continue to grow. Living in informal settlements accompanies a mire of social/health challenges that threatens upward mobility, but few studies exist that document drivers of mental health challenges in these settings. We investigated the prevalence and social determinants of poor mental health for young men in informal settlements adjacent to one of the largest cities that is at the heart of HIV endemic in South Africa. This study involved a cross-sectional study with cluster sampling design of 674 young men aged 18-30 years residing in eThekwini informal settlement communities. We assessed the prevalence, and social determinants, of significant depressive (i.e., depression) and post-traumatic stress (i.e., PTS) symptoms using logistic regression. Given the complex survey design of the study, all analyses were adjusted for clustering. The prevalence of depression and PTS in the sample was 46.8% and 14.4% respectively. Results of the multivariable analyses indicated that severe food insecurity (aOR = 2.98, 95% CI:1.70-5.22), crime perpetration (aOR = 1.51, 95% CI:1.05-3.80), severe adverse childhood event (aOR = 2.00, 95% CI: 1.05-3.80), traumatic event exposures (aOR = 2.43, 95% CI:1.56-3.80) and problematic alcohol use (aOR = 1.73, 95% CI:1.20-2.49) were significantly associated with depression. While incomplete secondary education (aOR = 0.45, 95% CI:0.22-0.92), moderate food insecurity (aOR = 2.51, 95% CI:1.04-6.06), traumatic event exposures (aOR = 2.19, 95% CI:1.32-3.64) and problematic alcohol use (aOR = 2.15, 95% CI: 1.24-3.73) were significantly associated with PTS. Our study highlights the exceedingly high levels of poor mental health among young men in informal settlements, with depression and PTS being driven by economic/social conditions. Multilevel interventions that address the individual, interpersonal, and social variables that contribute to poor mental health are needed.

Associations between psychosocial factors and antiretroviral therapy outcomes differ by gender and sexual orientation among people living with HIV in British Columbia, Canada.

Little is known about how the co-occurrence of psychosocial factors affect sub-populations of people living with HIV (PLWH). We used cross-sectional data from 999 PLWH, aged ≥19, accessing antiretroviral therapy (ART) in British Columbia, Canada (2007-2010) to examine associations between psychosocial factors and ART-related outcomes separately for trans/cis inclusive women; heterosexual men; and gay, bisexual, and other men who have sex with men (gbMSM). Multivariable logistic regression examined associations between psychosocial factors (0-3): any violence in the past 6 months, depressive symptoms in the past week, and current street drug use (heroin, crack, meth or speedball) with sub-optimal adherence (outcome 1: average annual ART adherence <95% from interview until end of follow-up, death, or December 31st, 2018) and ever viral rebound (outcome 2) adjusting for potential confounders. Of 999 PLWH (264 women, 382 heterosexual men, and 353 gbMSM), women and heterosexual men had significantly higher median counts than gbMSM. Overall, higher counts were associated with sub-optimal adherence (adjusted odds ratio [aOR] = 1.26/1-unit increase, 95%CI = 1.07-1.49). All effect estimates were of a greater magnitude among gbMSM, but not significant for women or heterosexual men, highlighting the need for population (e.g., gender and sexual orientation)-centered care and research.

Syndemics of intimate partner violence among women in HIV endemic South Africa: geospatial analysis of nationally representative data.

Despite some improvement in lowering HIV incidence, HIV-related challenges, such as intimate partner violence (IPV), remain unacceptably high among women in South Africa. For decades, researchers and activists have pointed to the complex and intertwined reality of the substance abuse, violence and AIDS (SAVA) syndemic that endangers women. However, more recent systematic review/meta-analysis evidence points to inconclusive association between IPV and alcohol use. Furthermore, much of the evidence is often non-population-based that focuses on the co-occurrence rather than synergistic SAVA interaction. In this study, using the latest data from the South Africa Demographic and Health Survey (SA-DHS), we identified geographic synergistic clustering of IPV associated with HIV and substance abuse in South Africa as a measure of population-level interactions among these factors. The SA-DHS is a nationally representative sample that includes wide-ranging data on health, social challenges and household geo-locations of 5,874 women who participated in the domestic violence module. First, geographical IPV, harmful alcohol use (as the substance abuse measure available in SA-DHS) and HIV clusters were identified using the Kulldorff spatial scan statistic in SaTScan. Second, synergistic interactions related to recent IPV (i.e. recent physical, sexual, emotional violence during the last 12 months) with harmful alcohol use and HIV challenge were measured using RERI [Relative excess risk due to interaction], AP [attributable proportion] and S [Synergy index]. In our results, we spatially identified geographical physical IPV syndemic interactions in parts of the Eastern Cape/Free State Provinces (RERI = 4.42 [95% CI: 2.34-6.51], AP = 0.56 [95% CI: 0.44-0.68], S = 2.77 [95% CI: 2.01-3.84], but not in other forms of IPV. Although IPV, based on decade old concept of SAVA syndemic, was less common/widespread than expected from the national scale population-based data, we identified population-level physical violence syndemic occurring in South Africa. Our study highlights the need to prioritize public health response targeting vulnerable populations residing in these high-risk areas of syndemic mechanisms linking these synergistic epidemics that women face in South Africa.

The sexual and reproductive health needs of school-going young people in the context of COVID-19 in rural KwaZulu-Natal, South Africa.

Background: The impact of school closures due to COVID-19 raised widespread concerns about children's health and well-being. We examine the impact on the sexual health needs of learners in the context of COVID-19 related lockdowns in rural KwaZulu-Natal, South Africa.Methods: In july-November 2020 and August-November 2021 we conducted 24 in-depth interviews and 8 group discussions with teachers and learners from 4 schools, community members and key education stakeholders. All interviews were conducted by telephone. We used a thematic analysis approach and Nvivo 12 software to manage the data.Results: Four main themes related to the COVID-19 pandemic emerged from the data: the sexual and reproductive health (SRH) of learners in the lead-up to the pandemic; the impact of COVID-19 on learners' SRH and wellbeing; the opportunities schools provided to support sexual well-being of learners during the pandemic; and the role of schools in supporting SRH for learners during the pandemic. Learners and stakeholders reported that the SRH of young people was affected by alcohol misuse, poor SRH knowledge and few pathways to link learners with services. Stakeholders working with schools reported that a lack of access to biomedical interventions (e.g., contraception) increased learner pregnancies. Gender-based violence in learners' households was reported to have increased during the COVID-19 pandemic related to loss of income. School closures disrupted the provision of a safe space to provide SRH and HIV-education through Life Orientation lessons and school nurse talks. This loss of a safe space also left learners vulnerable to sexual and physical violence. However, once schools re-opened, daily COVID-19 screening in schools provided the opportunity to identify and support vulnerable children who had other social needs (food and uniforms).Conclusion: The COVID-19 pandemic may have increased SRH needs and vulnerability of school-going children in a high HIV-burden rural setting. School shutdowns reduced the opportunity for schools to provide a vital safe space and information to enhance SRH for adolescents. Schools play a vital health promotion and social protection role.

Learners' viewpoints on the possibilities and limitations imposed by social contexts on online group-based participatory interventions to address violence.

Intimate partner violence (IPV) is a global public health concern amongst young people. Consequently, prevention efforts in the form of participatory interventions have been implemented, mainly in face-to-face settings. However, in recent years, there has been a growing interest to deliver participatory IPV prevention interventions online, and this has been exacerbated by COVID-19 imposed limitations. There remain concerns, however, about the impact social contexts may have on transformative communication in participatory interventions online. We conducted semi-structured interviews with 18 learners (14-19 years) from Eastern Cape province, South Africa, to understand the possibilities and limitations that social contexts impose on online participatory IPV prevention interventions. Access to devices, reliable internet, and privacy in homes provided opportunities for online IPV prevention interventions, while limited privacy, safety, concentration, and familiarity with some apps online challenged young people's interest in online IPV prevention interventions. We also found that young people's greatest concern was around achieving trust, privacy and safety online. More evidence is needed on how trust, privacy, and safety, supportive of transformative communication, can be achieved online. Further, young people are active and strategic in their engagements online and their potential to generate creative relevant solutions to address these challenges is highlighted.

Sexual Relationship Power Equity Is Associated With Consistent Condom Use and Fewer Experiences of Recent Violence Among Women Living With HIV in Canada.

BACKGROUND: Sexual relationship power (SRP) inequities, including having a controlling partner, have not been widely examined among women living with HIV (WLWH). We measured the prevalence and key outcomes of relationship control among WLWH in Canada. METHODS: Baseline data from WLWH (≥16 years), reporting consensual sex in the last month enrolled in a Canadian community-collaborative cohort study in British Columbia, Ontario, and Quebec, included the relationship control SRP subscale by Pulerwitz (2000). Scale scores were dichotomized into medium/low (score = 1-2.82) vs. high relationship control (score = 2.82-4), and high scores indicate greater SRP equity. Cronbach's alpha assessed scale reliability. Bivariate analyses compared women with high vs. medium/low relationship control. Crude and adjusted multinomial regression examined associations between relationship control and condom use [consistent (ref), inconsistent, or never]; any sexual, physical, and/or emotional violence; and physical and/or sexual violence [never (ref), recent (≤3 months ago), and previous (>3 months ago)]. RESULTS: Overall, 473 sexually active WLWH (33% of cohort), median age = 39 (IQR = 33-46) years, 81% on antiretroviral therapy, and 78% with viral loads <50 copies/mL were included. The subscale demonstrated good reliability (Cronbach's alpha = 0.92). WLWH with high relationship control (80%) were more likely ( P < 0.05) to be in a relationship, have no children, have greater resilience, and report less sociostructural inequities. In adjusted models, high relationship control was associated with lower odds of inconsistent vs. consistent condom use [adjusted odds ratio (aOR): 0.39 (95% confidence interval: 0.18 to 0.85)], any recent violence [aOR: 0.14 (0.04-0.47)] as well as recent physical and/or sexual [aOR : 0.05 (0.02-0.17)] but not previous violence (vs. never). DISCUSSION: Prioritizing relationship equity and support for WLWH is critical for addressing violence and promoting positive health outcomes.