An agricultural livelihood intervention is associated with reduced HIV stigma among people with HIV.

OBJECTIVE: HIV stigma undermines antiretroviral treatment (ART) adherence and viral suppression. Livelihood interventions may target drivers of negative attitudes towards people with HIV (PWH) by improving their health and strengthening their economic contributions. We examined the effects of a multisectoral agricultural livelihood intervention on HIV stigma among PWH in western Kenya. DESIGN: Sixteen health facilities were randomly allocated (1 : 1) to intervention or control arms in Shamba Maisha , a cluster randomized controlled trial that aimed to improve HIV-related health through behavioral, mental health, and nutritional pathways. METHODS: The intervention included a farming loan and agricultural and financial training. Participants had access to farmland and surface water and were at least 18 years old, on ART for more than 6 months, and moderately-to-severely food insecure. We measured internalized, anticipated, and enacted HIV stigma semiannually over 2 years using validated scales. In blinded intent-to-treat analyses, we compared changes in scores over 24 months by study arm, using longitudinal multilevel difference-in-differences linear regression models that accounted for clustering. RESULTS: Of 720 enrolled participants (354 intervention), 55% were women, and the median age was 40 years [interquartile range 34-47 years]. Two-year retention was 94%. Compared with the control arm, the intervention resulted in significant decreases ( P  < 0.001) of 0.42 points [95% confidence interval (CI) -0.52 to -0.31) in internalized stigma, 0.43 points (95% CI -0.51 to -0.34) in anticipated stigma, and 0.13 points (95% CI -0.16 to -0.09) in enacted stigma over 24 months. CONCLUSION: The agricultural livelihood intervention reduced HIV stigma among PWH. Poverty-reduction approaches may be a novel strategy for reducing HIV stigma.

Intersections of food insecurity, violence, poor mental health and substance use among US women living with and at risk for HIV: Evidence of a syndemic in need of attention.

BACKGROUND: Food insecurity and intimate partner violence (IPV) are associated with suboptimal HIV prevention and treatment outcomes, yet limited research has explored how food insecurity and IPV intersect to influence HIV-related behaviors. To fill this gap, we conducted a qualitative study with women living with or at risk for HIV in the United States. METHODS: We conducted 24 in-depth interviews with women enrolled in the San Francisco and Atlanta sites of the Women's Interagency HIV study (WIHS). Participants were purposively sampled so half were living with HIV and all reported food insecurity and IPV in the past year. Semi-structured interviews explored experiences with food insecurity and IPV, how these experiences might be related and influence HIV risk and treatment behaviors. Analysis was guided by an inductive-deductive approach. RESULTS: A predominant theme centered on how food insecurity and IPV co-occur with poor mental health and substance use to influence HIV-related behaviors. Women described how intersecting experiences of food insecurity and IPV negatively affected their mental health, with many indicating using substances to "feel no pain". Substance use, in turn, was described to perpetuate food insecurity, IPV, and poor mental health in a vicious cycle, ultimately facilitating HIV risk behaviors and preventing HIV treatment adherence. CONCLUSIONS: Food insecurity, IPV, poor mental health and substance use intersect and negatively influence HIV prevention and treatment behaviors. Findings offer preliminary evidence of a syndemic that goes beyond the more widely studied "SAVA" (substance use, AIDS, and violence) syndemic, drawing attention to additional constructs of mental health and food insecurity. Quantitative research must further characterize the extent and size of this syndemic. Policies that address the social and structural drivers of this syndemic, including multi-level and trauma-informed approaches, should be implemented and evaluated to assess their impact on this syndemic and its negative health effects.

Not Just Surviving, But Thriving: Overcoming Barriers to Career Advancement for Women Junior Faculty Clinician-Researchers.

OBJECTIVE: Although women attend medical school and residency at similar rates to men, they experience lower levels of academic career advancement than men. To inform national gender equity efforts, the authors conducted a qualitative study to explore potential gender differences in the career experiences of junior research faculty at a premier research institution. METHODS: Focus group discussions were conducted among women and men junior research faculty at the School of Medicine at an urban public research university. Participants were early mentored career development award recipients (K-awardees). Two same-gender focus groups of nine women and six men were conducted. Discussions focused on two domains: barriers to maintaining a research career and facilitators for research career development. Data were analyzed using ATLAS.ti and content analysis methods. RESULTS: Both women and men identified a challenging funding environment, difficulty bridging the salary gap, and lack of institutional support as barriers to maintaining their research careers. Women perceived two primary barriers to their career advancement that were different from their male counterparts: They were more likely to feel undervalued at the institution and to experience significant strains related to both childbearing and childcare. Women also reported receiving inadequate mentorship, having poor negotiation skills, and experiencing a lack of negotiation opportunities. CONCLUSIONS: Academic research institutions should consider interventions that provide financial, emotional, and practical support to women research faculty, particularly during their childbearing and childrearing years.

Relationship Power Among Same-Sex Male Couples in New York and San Francisco: Laying the Groundwork for Sexual Risk Reduction Interventions Focused on Interpersonal Power.

Research is clear that power differentials between women and men shape women's human immunodeficiency virus (HIV) risks; however, little research has attempted to examine power differentials within same-sex male (SSM) couples and whether these influence sexual risk outcomes. To produce the first quantitative scale that measures power in SSM relationships, the current work was a Phase 1 qualitative study that sought to understand domains of relationship power and how power operated in the relationship among 48 Black, White, and interracial (Black-White) SSM couples recruited from San Francisco and New York. Interview domains were focused on definitions of power and perceptions of how power operated in the relationship. Findings revealed that couples described power in three key ways: as power exerted over a partner through decision-making dominance and relationship control; as power to accomplish goals through personal agency; and as couple-level power. In addition, men described ways that decision-making dominance and relationship control could be enacted in the relationship-through structural resources, emotional and sexual influence, and gender norm expectations. We discuss the implications of these findings for sexual risks and HIV care and treatment with SSM couples that are focused on closing gaps in power.

A Qualitative Investigation of the Impact of a Livelihood Intervention on Gendered Power and Sexual Risk Behaviors Among HIV-Positive Adults in Rural Kenya.

Despite the recognized links between food insecurity, poverty, and the risk of HIV/AIDS, few randomized trials have evaluated the impact of livelihood interventions on HIV risk behaviors. The current study draws upon data collected from a qualitative process evaluation that was embedded into a pilot randomized controlled trial that tested whether a multisectoral agricultural intervention (Shamba Maisha) affected the HIV-related health of HIV-positive adults in rural Kenya. In the current study, we drew upon longitudinal, in-depth interviews with 45 intervention participants and nine control participants (N = 54) in order to examine the impacts of the intervention on gendered power and sexual risk reduction among both women and men. Female and male participants in the intervention described positive changes in sexual practices and gendered power dynamics as a result of intervention participation. Changes included reduced sexual risk behaviors, improved gender-related power dynamics, and enhanced quality of intimate relationships. These findings illuminate how a multisectoral agricultural intervention may affect inequitable gender relations and secondary transmission risk. Further research is needed to explore how to best leverage agricultural interventions to address the important intersections between poverty and inequitable gender relations that shape HIV risks.

"Is It All Right for Me to Have a Baby or Not?": Men Living With HIV Discuss Fertility Desires and Interactions With Providers.

To our knowledge, no study in the United States has qualitatively examined fertility desires, experiences communicating with health care providers about sexual and reproductive health, and attitudes toward reproductive counseling and services in men living with HIV (MLWH) who have sex with women. We conducted focus groups and interviews with MLWH (N = 17) who have sex with women seeking HIV care in San Francisco. The men conveyed limited awareness of safer conception strategies. While many men expressed the desire to have a child, most reported that their providers had not discussed reproduction with them. Participants highlighted the lack of HIV services for men who have sex with women and the need for improved reproductive counseling. We make recommendations for providers who work with MLWH who have sex with women and for patient-centered materials on safer conception, sexual HIV transmission risk reduction, and family planning strategies.

Does Integrating Family Planning into HIV Services Improve Gender Equitable Attitudes? Results from a Cluster Randomized Trial in Nyanza, Kenya.

This study investigated whether integrating family planning (FP) services into HIV care was associated with gender equitable attitudes among HIV-positive adults in western Kenya. Surveys were conducted with 480 women and 480 men obtaining HIV services from 18 clinics 1 year after the sites were randomized to integrated FP/HIV services (N = 12) or standard referral for FP (N = 6). We used multivariable regression, with generalized estimating equations to account for clustering, to assess whether gender attitudes (range 0-12) were associated with integrated care and with contraceptive use. Men at intervention sites had stronger gender equitable attitudes than those at control sites (adjusted mean difference in scores = 0.89, 95 % CI 0.03-1.74). Among women, attitudes did not differ by study arm. Gender equitable attitudes were not associated with contraceptive use among men (AOR = 1.06, 95 % CI 0.93-1.21) or women (AOR = 1.03, 95 % CI 0.94-1.13). Further work is needed to understand how integrating FP into HIV care affects gender relations, and how improved gender equity among men might be leveraged to improve contraceptive use and other reproductive health outcomes.

Integrating family planning into HIV care in western Kenya: HIV care providers' perspectives and experiences one year following integration.

With high rates of unintended pregnancy in sub-Saharan Africa, integration of family planning (FP) into HIV care is being explored as a strategy to reduce unmet need for contraception. Perspectives and experiences of healthcare providers are critical in order to create sustainable models of integrated care. This qualitative study offers insight into how HIV care providers view and experience the benefits and challenges of providing integrated FP/HIV services in Nyanza Province, Kenya. Sixteen individual interviews were conducted among healthcare workers at six public sector HIV care facilities one year after the implementation of integrated FP and HIV services. Data were transcribed and analyzed qualitatively using grounded theory methods and Atlas.ti. Providers reported a number of benefits of integrated services that they believed increased the uptake and continuation of contraceptive methods. They felt that integrated services enabled them to reach a larger number of female and male patients and in a more efficient way for patients compared to non-integrated services. Availability of FP services in the same place as HIV care also eliminated the need for most referrals, which many providers saw as a barrier for patients seeking FP. Providers reported many challenges to providing integrated services, including the lack of space, time, and sufficient staff, inadequate training, and commodity shortages. Despite these challenges, the vast majority of providers was supportive of FP/HIV integration and found integrated services to be beneficial to HIV-infected patients. Providers' concerns relating to staffing, infrastructure, and training need to be addressed in order to create sustainable, cost-effective FP/HIV integrated service models.

Sexuality in the Global South: 50 Years of Published Research in the Journal of Sex Research-Inclusions, Omissions, and Future Possibilities.

Sexuality researchers from a range of disciplines have called for more global inclusiveness in sexualities research, particularly in the Global South (GS). We investigated the degree to which sexuality researchers have published work focused on the GS by conducting a content analysis of 50 years of research published in the Journal of Sex Research (JSR). We examined all research articles, brief research reports, and clinical notes published in JSR from 1965 to 2014 (N = 1,626). Overall, a small percentage of articles focused on the GS with no increase over time (4.8%; N = 78). Articles in the GS focused on Asia (37.2%), Latin America (28.2%), Sub-Saharan Africa (23.1%), the Middle East (6.4%), and a mix of GS regions (5.1%). Topics related to sexual and reproductive health were most prevalent (19.2%), followed by articles on sexual risk, sexually transmitted infections (STIs), and human immunodeficiency virus (HIV) (17.9%), sexual norms, attitudes, and beliefs (16.7%), sex work (11.5%), cultural practices (10.3%), gay, lesbian, and bisexual issues (9.0%), intimate partner relationships (3.8%), and sexual violence (3.8%); the remaining categories (transgender and transsexual populations, sex research methods, sex testing, and women's sexuality) were negligible. We conclude with recommendations for improving the quantity, quality, and scope of global sexuality research in JSR.

'Women now wear trousers': men's perceptions of family planning in the context of changing gender relations in western Kenya.

Gender inequity has been closely linked with unmet need for family planning among women in sub-Saharan Africa but the factors related to male family planning disapproval are not well-understood. This qualitative study explored men's perspectives of gender roles and cultural norms as they pertain to family planning. Twelve small group meetings were held with 106 married men in Nyanza Province, Kenya. Shifting gender relations made the definitions of manhood more tenuous than ever. Men's previous identities as sole breadwinners, which gave them significant control over decision-making, were being undermined by women's increasing labour force participation. While many men viewed family planning positively, fears that family planning would lead to more female sexual agency and promiscuity or that male roles would be further jeopardised were widespread and were major deterrents to male family planning approval. By addressing such fears, gender-sensitive programmes could help more men to accept family planning. Increased family planning education for men is needed to dispel misconceptions regarding family planning side-effects. Focusing on the advantages of family planning, namely financial benefits and reduced conflict among couples, could resonate with men. Community leaders, outreach workers and healthcare providers could help shift men's approval of joint decision-making around family size to other reproductive domains, such as family planning use.

A randomized trial comparing the diagnostic accuracy of visual inspection with acetic acid to Visual Inspection with Lugol's Iodine for cervical cancer screening in HIV-infected women.

Visual inspection with Acetic Acid (VIA) and Visual Inspection with Lugol's Iodine (VILI) are increasingly recommended in various cervical cancer screening protocols in low-resource settings. Although VIA is more widely used, VILI has been advocated as an easier and more specific screening test. VILI has not been well-validated as a stand-alone screening test, compared to VIA or validated for use in HIV-infected women. We carried out a randomized clinical trial to compare the diagnostic accuracy of VIA and VILI among HIV-infected women. Women attending the Family AIDS Care and Education Services (FACES) clinic in western Kenya were enrolled and randomized to undergo either VIA or VILI with colposcopy. Lesions suspicious for cervical intraepithelial neoplasia 2 or greater (CIN2+) were biopsied. Between October 2011 and June 2012, 654 were randomized to undergo VIA or VILI. The test positivity rates were 26.2% for VIA and 30.6% for VILI (p = 0.22). The rate of detection of CIN2+ was 7.7% in the VIA arm and 11.5% in the VILI arm (p = 0.10). There was no significant difference in the diagnostic performance of VIA and VILI for the detection of CIN2+. Sensitivity and specificity were 84.0% and 78.6%, respectively, for VIA and 84.2% and 76.4% for VILI. The positive and negative predictive values were 24.7% and 98.3% for VIA, and 31.7% and 97.4% for VILI. Among women with CD4+ count < 350, VILI had a significantly decreased specificity (66.2%) compared to VIA in the same group (83.9%, p = 0.02) and compared to VILI performed among women with CD4+ count ≥ 350 (79.7%, p = 0.02). VIA and VILI had similar diagnostic accuracy and rates of CIN2+ detection among HIV-infected women.

Men's knowledge and attitudes about cervical cancer screening in Kenya.

BACKGROUND: A number of studies have identified male involvement as an important factor affecting reproductive health outcomes, particularly in the areas of family planning, antenatal care, and HIV care. As access to cervical cancer screening programs improves in resource-poor settings, particularly through the integration of HIV and cervical cancer services, it is important to understand the role of male partner support in women's utilization of screening and treatment. METHODS: We administered an oral survey to 110 men in Western Kenya about their knowledge and attitudes regarding cervical cancer and cervical cancer screening. Men who had female partners eligible for cervical cancer screening were recruited from government health facilities where screening was offered free of charge. RESULTS: Specific knowledge about cervical cancer risk factors, prevention, and treatment was low. Only half of the men perceived their partners to be at risk for cervical cancer, and many reported that a positive screen would be emotionally upsetting. Nevertheless, all participants said they would encourage their partners to get screened. CONCLUSIONS: Future interventions should tailor cervical cancer educational opportunities towards men. Further research is needed among both men and couples to better understand barriers to male support for screening and treatment and to determine how to best involve men in cervical cancer prevention efforts.