Stigmatization of people who inject drugs (PWID) by pharmacists in Tajikistan: sociocultural context and implications for a pharmacy-based prevention approach.

BACKGROUND: Pharmacies are an important source of sterile syringes for people who inject drugs (PWID) in Tajikistan who are under high risk of HIV and hepatitis C virus. Accessibility of sterile syringes at pharmacies without prescription may depend on pharmacists' attitudes towards PWID. This qualitative inquiry examines meanings and processes of stigmatization of PWID among pharmacists and pharmacy students in Tajikistan. METHODS: We conducted semi-structured interviews with 19 pharmacists and 9 students (N = 28) in the cities of Dushanbe and Kulob, Tajikistan. The interview topics included personal attitudes towards drug use and PWID, encounters with PWID, awareness and beliefs related to drug dependence and HIV, and attitudes and practices related to providing syringes to PWID. Interview transcripts were analysed using thematic analysis methods. RESULTS: The main themes included the significance of religion in defining attitudes towards drug use, labelling of PWID, negative stereotypes (PWID are prone to crime, violence, and irrational aggression; inflict harm to families and society; are able to control drug use), emotions triggered by PWID (fear, sympathy) and discrimination against PWID (rejection, isolation, ostracism, limiting resources to PWID). The religious ban on drug use and pharmacists' moral and legal responsibility for the consequences of drug use were frequently mentioned as reasons for rejecting syringe sales. Still, many participants acknowledged the need for distributing syringes to PWID to prevent HIV. CONCLUSIONS: Stigma against PWID in Tajikistan plays an important role in shaping pharmacists' attitudes towards provision of services to this population. Local sociocultural context, in particular religious beliefs and social conservatism, may facilitate stigmatizing beliefs.

Not everyone can afford an apple a day: stigma and food insecurity in rural South African young adults.

The HIV epidemic in South Africa has created a generation of orphaned and vulnerable children (OVCs). Little is known about the experiences of these "former" OVCs once they pass their 18th birthday. We conducted a qualitative study to understand the experiences of food insecurity for rural South African young adults. We conducted 20 in-depth interviews with 11 men and 9 women aged 18-25, and 2 focus group discussions. Many ate a single meal a day provided by the school feeding scheme or by friends. Despite this, nearly all participants emphasised the emotional and social, rather than the physical, tolls of food insecurity. These experiences of social shame predominantly stem from instrumental stigma - the perception within the broader community that because these former OVCs lived in relative poverty they would not be able to contribute to the web of community ties which function as a social safety net. Interventions designed to support former OVCs must focus on building social capital and supporting emotional resiliency in addition to providing material support.

Perpetration of physical and sexual abuse and subsequent fathering of pregnancies among a cohort of young South African men: a longitudinal study.

BACKGROUND: Young men's involvement in fathering pregnancies has been substantially neglected in unintended pregnancy research. Gender norms give men substantial power and control over sexual encounters, suggesting that understanding men's role is imperative. We tested the hypothesis that young, unmarried South African men who had perpetrated intimate partner violence (IPV) have a greater incidence of fathering pregnancies. METHODS: The data for this study were collected from 983 men aged 15 to 26 who participated in a 2-year community randomized controlled HIV prevention trial in the rural Eastern Cape. Multivariate Poisson models investigated the associations between baseline perpetration of IPV and fathering subsequent pregnancies, while controlling for age, number of sexual partners, socio-economic status, educational attainment, problematic alcohol use, exposure to the intervention, and time between interviews. RESULTS: Of the men in this study, 16.5% (n = 189) had made a girlfriend pregnant over two years of follow up. In addition, 39.1% had perpetrated physical or sexual intimate partner violence and 24.3% had done so more than once. Men who at baseline had perpetrated IPV in the previous year had an increased incidence of fathering, for a first perpetration in that year IRR 1.67 (95% CI 1.14-2.44) and among those who had also been previously violent, IRR 1.97 (95% CI 1.31-2.94). Those who had ever been violent, but not in the past year, did not have an elevated incidence. The incidence among men who had ever perpetrated physical abuse was less elevated than among those who had perpetrated physical and sexual violence IRR 1.64 (95% CI 1.18-2.29) versus IRR 2.59 (95% CI 1.64-4.10) indicating a dose response. CONCLUSION: Young men's perpetration of partner violence is an important predictor of subsequently fathering a pregnancy. The explanation may lie with South African hegemonic masculinity, which valorizes control of women and displays of heterosexuality and virility, and compromises women's reproductive choices.

Prevalence of consensual male-male sex and sexual violence, and associations with HIV in South Africa: a population-based cross-sectional study.

BACKGROUND: In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male-male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus. METHODS AND FINDINGS: In a cross-sectional study conducted in 2008, men aged 18-49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (n = 92) of participants reported a lifetime history of any consensual sexual activity with another man; 9.6% (n = 164) reported any sexual victimization by a man, and 3.0% (n = 51) reported perpetrating sexual violence against another man. 85.0% (n = 79) of men with a history of consensual sex with men reported having a current female partner, and 27.7% (n = 26) reported having a current male partner. Of the latter, 80.6% (n = 21/26) also reported having a female partner. Men reporting a history of consensual male-male sexual behavior are more likely to have been a victim of male-on-male sexual violence (adjusted odds ratio [aOR] = 7.24; 95% CI 4.26-12.3), and to have perpetrated sexual violence against another man (aOR = 3.10; 95% CI 1.22-7.90). Men reporting consensual oral/anal sex with a man were more likely to be HIV+ than men with no such history (aOR = 3.11; 95% CI 1.24-7.80). Men who had raped a man were more likely to be HIV+ than non-perpetrators (aOR = 3.58; 95% CI 1.17-10.9). CONCLUSIONS: In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male-female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male-male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.

Male-on-male intimate partner violence and sexual risk behaviors among money boys and other men who have sex with men in Shanghai, China.

BACKGROUND: Intimate partner violence (IPV) is known to increase HIV risk among heterosexual women, but less is known about IPV and HIV among men who have sex with men (MSM), with almost no data from non-Western countries. This study examined the prevalence of IPV and links between IPV and HIV risks among MSM in Shanghai, China. METHODS: A cross-sectional sample of 404 money boys (male sex workers) and other MSM were recruited via respondent-driven sampling. RESULTS: Overall, 51% of the sample reported emotional, physical, or sexual abuse from a male sexual partner. Money boys reported more overall abuse than did other MSM, and more were likely than other MSM to report experiencing multiple types of abuse. MSM who reported violence or abuse from male partners reported more overall sexual risk behavior, and specifically, more unprotected sex and more sex linked to alcohol and other substance use. The association between experience of abuse from male partners and increased HIV risk did not differ between money boys and other Chinese MSM. CONCLUSIONS: We conclude that violence and abuse from male partners are highly prevalent among Chinese MSM, and that experience of violence from male sexual partners is linked to increased HIV risk. HIV prevention targeting Chinese MSM must address the increased risk associated with experience of male-on-male IPV. Future research should explore links between HIV risk and MSM's perpetration of violence against male partners, as well as exploring the role of violence in the male-female relationships of men who have sex with and men and women.

Prevalence and factors associated with depressive symptoms among young women and men in the Eastern Cape Province, South Africa.

PURPOSE: There is little research on prevalence of depressive symptoms and associated factors among youth in sub-Saharan Africa. This paper explores factors associated with depressive symptomatology in South Africa. METHODS: A cross-sectional analysis of interviews with 1 415 women and 1 368 men aged 15-26 was undertaken. The Centre for Epidemiological Studies on Depression Scale (CESD Scale) was used to establish depressive symptomatology. RESULTS: The prevalence of depressive symptoms was 20.5% in women and 13.5% in men. For women, depressive symptoms were associated with increased childhood adversity (aOR 1.34 95% CI 1.116, 1.55); drug use (aOR 1.98 CI 1.17, 3.35); experience of intimate partner violence (aOR 2.21 CI 1.16, 3.00); sexual violence before the age of 18 years (aOR 1.45 CI 1.02, 2.02) and lower perceptions of community cohesion (aOR 1.23 CI 1.07, 1.40). For men, depressive symptoms were associated with a mother's death (aOR 2.24 CI 1.25, 4.00); childhood adversity (aOR 1.61 CI 1.38, 1.88); alcohol abuse (aOR 1.63 CI 1.13, 2.35), sexual coercion by a woman (aOR 2.36 CI 1.47, 3.80) and relationship conflict (aOR 1.07 CI 1.01, 1.12). CONCLUSIONS: Depressive symptoms were more highly prevalent in women than in men. Depressed mood was associated with childhood adversity, sexual violence and substance misuse in both women and men. This study further suggests gender differences in that for women, depressive symptoms were associated with intimate partner violence and lower perceptions of community cohesion, while for men the associations were with a mother's death and relationship conflict.

Economically motivated relationships and transactional sex among unmarried African American and white women: results from a U.S. national telephone survey.

OBJECTIVE: We explored links among economically motivated relationships, transactional sex, and risk behavior for human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) among unmarried African American and white women. METHODS: We drew on data from 1,371 unmarried African American and white women aged 20 to 45 years that we collected via a random-digit-dial telephone survey in the U.S. RESULTS: Of all respondents, 33.3% (95% confidence interval 28.8, 38.0) reported staying in a relationship longer than they wanted to because of economic considerations. African American women were more likely than white women to report starting a relationship due to economic considerations (21.6% vs. 10.5%) and having transactional sex with someone who was not a regular partner (13.1% vs. 2.9%). These behaviors were all associated with lack of education, experience of economic hardship, need to care for dependents, and increased levels of HIV/STI risk. All three behaviors were associated with having more sexual partners. Staying in a sexual relationship because of economic considerations was also associated with anal sex, reduced condom use, and concurrent sexual partnerships. Transactional sex with non-regular partners was associated with concurrent sexual partnerships, binge drinking, drug use, perceived concurrency by main partner, and having high-risk sexual partners. CONCLUSION: HIV/STI risk-reduction policies and programs in the U.S. need to explicitly address overall economic disempowerment among women, as well as racial disparities in poverty. These economic disparities likely contribute both to increasing rates of HIV among women in the U.S. and to the extraordinary racial disparities in HIV/STI risk among American women.

Longitudinal Trajectories of Physical Intimate Partner Violence Among Adolescent Girls in Rural South Africa: Findings From HPTN 068.

PURPOSE: Little is known about temporal patterns of physical intimate partner violence (PIPV) among South African adolescent girls. We sought to identify and describe PIPV risk trajectories and related correlates in this population. METHODS: Our analytical cohort came from the HPTN 068 Cash Transfer Trial in Mpumalanga Province, South Africa. Cohort members were eighth and ninth graders (median age 14 years) who enrolled in 2011 and had three to four annual, self-reported PIPV measurements. We used group-based trajectory models to identify groups of girls with similar longitudinal patterns of PIPV risk over 4 years and potential correlates of group membership. RESULTS: We identified two trajectory groups (n = 907): a higher-risk group (~52.8% of the cohort) with predicted PIPV probabilities of 13.5%-41.1% over time and a lower-risk group (~47.2% of the cohort) with predicted probabilities of 2.3%-10.3%. Baseline correlates of higher-risk group membership were ever having had sex (adjusted odds ratio [aOR]: 4.42, 95% confidence interval [CI]: 1.56-12.57), borrowing money (aOR: 1.95, 95% CI: 1.01-3.79), and older age (aOR per 1-year increase: 1.39, 95% CI: 1.11-1.73), while being in the 068 intervention arm (aOR: .29, 95% CI: .17-.51) and supporting more gender-equitable norms (aOR per 1-unit score increase: .89, 95% CI: .81-.97) were inversely associated. CONCLUSIONS: A high proportion of adolescent girls experience sustained PIPV risk in rural South Africa, suggesting a need for interventions in late primary school that encourage gender-equitable norms, healthy relationships, and safe ways to earn income during adolescence.

New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data.

BACKGROUND: Sub-Saharan Africa has a high rate of HIV infection, most of which is attributable to heterosexual transmission. Few attempts have been made to assess the extent of HIV transmission within marriages, and HIV-prevention efforts remain focused on abstinence and non-marital sex. We aimed to estimate the proportion of heterosexual transmission of HIV which occurs within married or cohabiting couples in urban Zambia and Rwanda each year. METHODS: We used population-based data from Demographic and Health Surveys (DHS) on heterosexual behaviour in Zambia in 2001-02 and in Rwanda in 2005. We also used data on the HIV serostatus of married or cohabiting couples and non-cohabiting couples that was collected through a voluntary counselling and testing service for urban couples in Lusaka, in Zambia, and Kigali, in Rwanda. We estimated the probability that an individual would acquire an incident HIV infection from a cohabiting or non-cohabiting sexual partner, and then the proportion of total heterosexual HIV transmission which occurs within married or cohabiting couples in these settings each year. FINDINGS: We analysed DHS data from 1739 Zambian women, 540 Zambian men, 1176 Rwandan women, and 606 Rwandan men. Under our base model, we estimated that 55.1% to 92.7% of new heterosexually acquired HIV infections among adults in urban Zambia and Rwanda occurred within serodiscordant marital or cohabiting relationships, depending on the sex of the index partner and on location. Under our extended model, which incorporated the higher rates of reported condom use that we found with non-cohabiting partners, we estimated that 60.3% to 94.2% of new heterosexually acquired infections occurred within marriage or cohabitation. We estimated that an intervention for couples which reduced transmission in serodiscordant urban cohabiting couples from 20% to 7% every year could avert 35.7% to 60.3% of heterosexually transmitted HIV infections that would otherwise occur. INTERPRETATION: Since most heterosexual HIV transmission for both men and women in urban Zambia and Rwanda takes place within marriage or cohabitation, voluntary counselling and testing for couples should be promoted, as should other evidence-based interventions that target heterosexual couples.

Pharmacists' attitudes and practices about selling syringes to people who inject drugs in Tajikistan: Results of a syringe purchase audit and a survey.

BACKGROUND: In Tajikistan, governmental policies leave the decision whether or not to sell syringes to people who inject drugs (PWID) to pharmacists' discretion. This exploratory study tests a theory-driven model explaining Tajikistani pharmacists' actual syringe sale practices to inform future HIV advocacy activities. METHODS: Data were collected via attempts to purchase syringes without prescription and a subsequent survey among a sample of 232 pharmacists in two cities (Dushanbe and Kulob) in Tajikistan in 2015. The survey collected data on attitudes and beliefs related to selling syringes to PWID, stigma against PWID and background contextual factors such as social conservatism, HIV and drug use knowledge. Structural equation modelling was used to assess the relationships between syringe sale practice and pharmacists' attitudinal and background factors. RESULTS: The majority (87.9%, n = 204) of sampled pharmacists agreed to sell syringes to the study research assistants without a prescription. According to the final model, agreeing to sell syringes was moderately associated with the reported intent to provide syringes without prescription (ß = 0.36, p < 0.001), lower stigma against PWID (ß=-0.43, p = 0.01), and stronger social conservatism (ß = 0.35, p = 0.02). Intent to provide syringes correlated with positive attitudes towards provision of syringes (ß = 0.35, p = 0.008), which in turn were negatively associated with stigma (ß=-0.54, p < 0.001) and positively with age (ß = 0.20, p = 0.03). Stigma against PWID was directly associated with social conservatism (ß = 0.47, p < 0.001) and inversely with university-level education (ß=-0.28, p < 0.001). CONCLUSION: We demonstrated the accessibility of over-the-counter syringes in urban pharmacies of Tajikistan and emphasized the role of stigma in shaping pharmacists' syringe sale practices. Advocacy interventions should target pharmacists to reduce stigmatization of PWID and ensure access to clean syringes.

Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: prevalence, predictors, and associations with gender-based violence.

We explored the prevalence and predictors of transactional sex with casual partners and main girlfriends among 1288 men aged 15-26 from 70 villages in the rural Eastern Cape province of South Africa. Data were collected through face-to-face interviews with young men enroling in the Stepping Stones HIV prevention trial. A total of 17.7% of participants reported giving material resources or money to casual sex partners and 6.6% received resources from a casual partner. Transactionally motivated relationships with main girlfriends were more balanced between giving (14.9%) and getting (14.3%). We constructed multivariable models to identify the predictors for giving and for getting material resources in casual and in main relationships. Each model resulted in remarkably similar predictors. All four types of exchange were associated with higher socio-economic status, more adverse childhood experiences, more lifetime sexual partners, and alcohol use. Men who were more resistant to peer pressure to have sex were less likely to report transactional sex with casual partners, and men who reported more equitable gender attitudes were less likely to report main partnerships underpinned by exchange. The most consistent predictors of all four types of transaction were perpetration of intimate partner violence and rape against women other than a main partner. The strong and consistent association between perpetration of gender-based violence and both giving and getting material goods from female partners suggests that transactional sex in both main and casual relationships should be viewed within a broader continuum of men's exercise of gendered power and control. HIV prevention interventions need to explicitly address transactional sex in the context of ideas about masculinity, which place a high emphasis on heterosexual success with, and control of, women.

Agency as a mediator in the pathway from transactional sex to HIV among pregnant women in Swaziland: a multigroup path analysis.

INTRODUCTION: Transactional sex is a structural driver of HIV for women and girls in sub-Saharan Africa. In transactional relationships, sexual and economic obligations intertwine and may have positive and negative effects on women's financial standing and social status. We conducted a clinic-based survey with pregnant women in Swaziland using a locally validated transactional sex scale to measure the association between subjective social status, transactional sex, and HIV status, and to assess whether this association differed according to a woman's agency within her relationship. METHODS: We recruited a convenience sample of 406 pregnant women at one rural and one urban public antenatal clinic in Swaziland and administered a behavioural survey that was linked to participant HIV status using clinic records. We then conducted a multigroup path analysis to test three hypotheses: (1) that more engagement in transactional sex is associated with decreased condom use and increased subjective social status; (2) that subjective social status mediates the relationship between transactional sex and HIV status; and (3) that these relationships are different across groups according to whether or not a woman reported any indicator of constrained agency within her relationship. RESULTS: The amount and value of material goods received from a sexual partner was significantly and positively associated with higher subjective social status among all participants. As the amount of material goods received from a partner increased, women who reported no indicators of constrained agency were less likely to use condoms. Conversely, there was no relationship between transactional sex and condom use among women who reported any indicator of constrained relationship agency. Among women who reported any indicator of constrained agency, HIV was significantly associated with lower subjective social status. CONCLUSIONS: Relationship agency likely plays a key role in determining which mechanisms create HIV risk for women in transactional relationships. Interventions to mitigate these risks must address social forces that penalize women who engage in sexual relationships as well as structural drivers of gendered economic disparity that reduce women's agency within their sexual and romantic relationships.

Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa.

OBJECTIVES: To examine associations between the perpetration of intimate partner violence and HIV risk behaviour among young men in rural South Africa. DESIGN: An analysis of baseline data from men enrolling in a randomized controlled trial of the behavioural intervention, Stepping Stones. METHODS: Structured interviews with 1275 sexually experienced men aged 15-26 years from 70 villages in the rural Eastern Cape. Participants were asked about the type, frequency, and timing of violence against female partners, as well as a range of questions about HIV risk behaviours. RESULTS: A total of 31.8% of men reported the perpetration of physical or sexual violence against female main partners. Perpetration was correlated with higher numbers of past year and lifetime sexual partners, more recent intercourse, and a greater likelihood of reporting casual sex partners, problematic substance use, sexual assault of non-partners, and transactional sex. Men who reported both physical and sexual violence against a partner, perpetration both before and within the past 12 months, or more than one episode of perpetration reported significantly higher levels of HIV risk behaviour than men who reported less severe or less frequent perpetration of violence. CONCLUSION: Young men who perpetrate partner violence engage in significantly higher levels of HIV risk behaviour than non-perpetrators, and more severe violence is associated with higher levels of risky behaviour. HIV prevention interventions must explicitly address the links between the perpetration of intimate partner violence and HIV risk behaviour among men, as well as the underlying gender and power dynamics that contribute to both.

The feminine ideal and transactional sex: Navigating respectability and risk in Swaziland.

Women who engage in transactional sex are not only at increased risk of HIV and intimate partner violence, but also face social risks including gossip and ostracism. These social and physical risks may be dependent on both what a woman expects and needs from her partner and how her community perceives the relationship. Gender theory suggests that some of these social risks may hinge on whether or not a woman's relationship threatens dominant masculinity. We conducted a qualitative study in Swaziland from September 2013 to October 2014 to explore transactional sex and respectable femininity through the lens of hegemonic gender theory. Using cultural consensus modeling, we identified cultural models of transactional sex and conducted 16 in-depth interviews with model key informants and 3 focus group discussions, for a total of 41 participants. We identified 4 main models of transactional relationships: One typified by marriage and high social respectability, a second in which women aspire towards marriage, a third particular to University students, and a fourth "sugar daddy" model. Women in all models expected and received significant financial support from their male partners. However, women in less respectable relationships risked social censure and stigma if they were discovered, in part because aspects of their relationship threatened hegemonic masculinity. Conversely, women who received male support in respectable relationships had to carefully select HIV risk reduction strategies that did not threaten their relationship and associated social status. Research and programming efforts typically focus only on the less socially respectable forms of transactional sex. This risks reinforcing stigma for women in relationships that are already considered socially unacceptable while ignoring the unique HIV risks faced by women in more respectable relationships.

Cultural consensus modeling to measure transactional sex in Swaziland: Scale building and validation.

Transactional sex is associated with increased risk of HIV and gender based violence in southern Africa and around the world. However the typical quantitative operationalization, "the exchange of gifts or money for sex," can be at odds with a wide array of relationship types and motivations described in qualitative explorations. To build on the strengths of both qualitative and quantitative research streams, we used cultural consensus models to identify distinct models of transactional sex in Swaziland. The process allowed us to build and validate emic scales of transactional sex, while identifying key informants for qualitative interviews within each model to contextualize women's experiences and risk perceptions. We used logistic and multinomial logistic regression models to measure associations with condom use and social status outcomes. Fieldwork was conducted between November 2013 and December 2014 in the Hhohho and Manzini regions. We identified three distinct models of transactional sex in Swaziland based on 124 Swazi women's emic valuation of what they hoped to receive in exchange for sex with their partners. In a clinic-based survey (n = 406), consensus model scales were more sensitive to condom use than the etic definition. Model consonance had distinct effects on social status for the three different models. Transactional sex is better measured as an emic spectrum of expectations within a relationship, rather than an etic binary relationship type. Cultural consensus models allowed us to blend qualitative and quantitative approaches to create an emicly valid quantitative scale grounded in qualitative context.

The gender dimensions of social networks and help-seeking behaviors of young adults in Soweto, South Africa.

BACKGROUND: Young people constitute a major proportion of the general population and are influenced by a variety of factors, especially in regards to seeking help. An understanding of help-seeking behaviors among young people is important for designing and implementing effective targeted health services. METHODS: We conducted in-depth interviews with 23 young adults aged 21-22 years in Soweto, South Africa, to explore the gender dimensions of social networks and help-seeking behaviors. RESULTS: We found that young men had larger peer social networks than young women and that young women's social networks centered on their households. For general health, both young men and young women often sought help from an older, maternal figure. However, for sexual health, young men consulted their group of peers, whereas young women were more likely to seek information from one individual, such as an older female friend or family member. CONCLUSION: These differences in help-seeking behaviors have important implications for the delivery of health information in South Africa and how health promotion is packaged to young men and women, especially for sexual and reproductive health issues. Peer educators might be very effective at conveying health messages for young men, whereas women might respond better to health information presented in a more confidential setting either through community health workers or mHealth technologies. Provision of or linkage to health services that is consistent with young people's health-seeking behavior, such as using peer educators and community health care workers, may increase the reach and utilization of these services among young people.

The Development and Validation of the Indian Family Violence and Control Scale.

The high prevalence of domestic violence (DV) among married women in India and associated negative health repercussions highlight the need for effective prevention strategies and tools to measure the efficacy of such interventions. Literature supporting differing manifestations of DV by culture underscores the need for a culturally-tailored scale to more effectively measure DV in the Indian context. We therefore aimed to develop and validate such a tool, the Indian Family Violence and Control Scale (IFVCS), through a mixed-methods study. The psychometric development of IFVCS is herein discussed. After field pre-testing and expert review, a 63-item questionnaire was administered to a random sample of 630 married women from May-July 2013 in Pune, India. The item response theory approach for binary data to explore the IFVCS structure suggested that IFVCS is reliable, with the majority of items having high (>0.5) and significant factor loadings. Concurrent validity, assessed by comparing responses to IFVCS with the validated, abridged Conflict Tactics Scale-2, was high (r = 0.899, p<0.001) as was the construct validity, demonstrated by its significant association with several established DV correlates. Therefore, initial assessment of the IFVCS psychometric properties suggests that it is an effective tool for measuring DV among married women in India and speaks to its capacity for enhancing understanding of DV epidemiology and for evaluating the effectiveness of future DV interventions.

Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa.

BACKGROUND: Gender-based violence and gender inequality are increasingly cited as important determinants of women's HIV risk; yet empirical research on possible connections remains limited. No study on women has yet assessed gender-based violence as a risk factor for HIV after adjustment for women's own high-risk behaviours, although these are known to be associated with experience of violence. METHODS: We did a cross-sectional study of 1366 women presenting for antenatal care at four health centres in Soweto, South Africa, who accepted routine antenatal HIV testing. Private face-to-face interviews were done in local languages and included assessement of sociodemographic characteristics, experience of gender-based violence, the South African adaptation of the Sexual Relationship Power Scale (SRPS), and risk behaviours including multiple, concurrent, and casual male partners, and transactional sex. FINDINGS: After adjustment for age and current relationship status and women's risk behaviour, intimate partner violence (odds ratio 1.48, 95% CI 1.15-1.89) and high levels of male control in a woman's current relationship as measured by the SRPS (1.52, 1.13-2.04) were associated with HIV seropositivity. Child sexual assault, forced first intercourse, and adult sexual assault by non-partners were not associated with HIV serostatus. INTERPRETATION: Women with violent or controlling male partners are at increased risk of HIV infection. We postulate that abusive men are more likely to have HIV and impose risky sexual practices on partners. Research on connections between social constructions of masculinity, intimate partner violence, male dominance in relationships, and HIV risk behaviours in men, as well as effective interventions, are urgently needed.

How well does the World Health Organization definition of domestic violence work for India?

Domestic violence (DV) is reported by 40% of married women in India and associated with substantial morbidity. An operational research definition is therefore needed to enhance understanding of DV epidemiology in India and inform DV interventions and measures. To arrive at a culturally-tailored definition, we aimed to better understand how definitions provided by the World Health Organization and the 2005 India Protection of Women from Domestic Violence Act match the perceptions of behaviors constituting DV among the Indian community. Between September 2012 and January 2013, 16 key informant interviews with experts in DV and family counseling and 2 gender-concordant focus groups of lay community members were conducted in Pune, India to understand community perceptions of the definition of DV, perpetrators of DV, and examples of DV encountered by married women in Pune, India. Several key themes emerged regarding behaviors and acts constituting DV including 1) the exertion of control over a woman's reproductive decision-making, mobility, socializing with family and friends, finances, and access to food and nutrition, 2) the widespread acceptance of sexual abuse and the influences of affluence on sexual DV manifestations, 3) the shaping of physical abuse experiences by readily-available tools and the presence of witnesses, 4) psychological abuse for infertility, dowry, and girl-children, and 5) the perpetration of DV by the husband and other members of his family. Findings support the need for a culturally-tailored operational definition that expands on the WHO surveillance definition to inform the development of more effective DV intervention strategies and measures.

Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection.

Sex workers have long been considered a high-risk group for HIV infection, but to date little quantitative research has explored the association between HIV risk and exchange of sex for material gain by women in the general population. The objective of this study was to estimate the prevalence of such transactional sex among women attending antenatal clinics in Soweto, South Africa, to identify demographic and social variables associated with reporting transactional sex, and to determine the association between transactional sex and HIV serostatus. We conducted a cross-sectional study of women seeking antenatal care in four Soweto health centres who accepted routine antenatal HIV testing. Private face-to-face interviews covered socio-demographics, sexual history and experience of gender-based violence. 21.1% of participants reported having ever had sex with a non-primary male partner in exchange for material goods or money. Women who reported past experience of violence by male intimate partners, problematic substance use, urban residence, ever earning money, or living in substandard housing were more likely to report transactional sex, while women who reported delayed first coitus, were married, or had a post-secondary education were less likely to report transactional sex. Transactional sex was associated with HIV seropositivity after controlling for lifetime number of male sex partners and length of time a woman had been sexually active (OR = 1.54, 95% CI: 1.07, 2.21). Women who reported non-primary partners without transactional sex did not have increased odds of being HIV seropositive (OR = 1.04, 95% CI: 0.75, 1.43). We conclude that transactional sex may place women at increased risk for HIV, and is associated with gender-based violence, substance use and socio-economic disadvantage. Research, policy and programmatic initiatives should consider the role of transactional sex in women's HIV risk, with attention to the intersecting roles of violence, poverty, and substance use in shaping women's sexual behaviour.