Experience of and factors associated with violence against sexual and gender minorities in nine African countries: a cross-sectional study.

OBJECTIVE: The objective of this research was to assess physical and sexual violence experienced by sexual and gender minorities in nine African countries, and to examine factors associated with violence. METHODS: We conducted an exploratory multi-country cross-sectional study among self-identifying sexual and gender minorities, using a survey tool available in paper and online. Participants were sampled through venue-based and web-based convenience sampling. We analysed data using descriptive statistics and logistic regression, with Stata15. FINDINGS: Of 3798 participants, 23% were gender minorities, 20% were living with HIV, and 18% had been coerced into marriage. Fifty-six per cent of all participants had experienced physical or sexual violence in their lifetime, and 29% in the past year. Gender minorities had experienced significantly higher levels of violence compared to cisgender (sexual minority) participants. The variable most strongly associated with having experienced violence was being coerced into marriage (AOR, 3.02), followed by people living nearby knowing about one's sexual orientation and/or gender identity (AOR, 1.90) and living with HIV (AOR, 1.47). CONCLUSION: Sexual and gender minorities in Eastern and Southern Africa experience high levels of violence. Sexual orientation and gender identity need to be recognised as risk factors for violence in national and regional law and policy frameworks. States should follow the African Commission Resolution 275 and provide protection against violence based on real or perceived sexual orientation or gender identity.

Understanding abortion seeking care outside of formal health care settings in Cape Town, South Africa: a qualitative study.

BACKGROUND: Although abortion was legalized in South Africa in 1996, barriers to safe, legal abortion services remain, and women continue to seek abortions outside of the formal healthcare sector. This study explored the decision-making processes that women undertake when faced with an unintended pregnancy, the sources of information used to make their decisions and the factors that contribute to their seeking of informal sector abortion in Cape Town, South Africa. METHODS: We conducted 15 semi-structured in-depth interviews in English with women who had accessed an abortion outside of the formal health care sector. Women were recruited with the assistance of a community-based key informant. Data was analyzed using a thematic analysis approach. RESULTS: Participants were aware that abortions were legal and accessible in public clinics, however they were concerned that others would find out about their unintended pregnancy and abortion if they went to legal providers. Women were also concerned about judgment and mistreatment from providers during their care. Rather than seek care in the formal sector, women looked past concerns around the safety and effectiveness of informal sector abortions and often relied on their social networks for referrals to informal providers. CONCLUSIONS: The findings highlight the decision-making processes employed by women when seeking abortion services in a setting where abortion is legal and demonstrate the role of institutional and societal barriers to safe abortion access. Abortion service delivery models should adapt to women's needs to enhance the preferences and priorities of those seeking abortion care-including those who prefer facility-based care as well as those who might prefer self-managed medical abortions.

Although abortion was legalized in South Africa in 1996, barriers to safe, legal abortion services remain, and women continue to seek abortions outside of the formal healthcare sector. This study explored the decision-making processes that women undertake when faced with an unintended pregnancy, who they discuss and seek help from, and the factors that influence their decision to seek an abortion outside of the formal health care sector. We interviewed 15 women who had obtained an abortion outside of the health care sector in Cape Town, South Africa. Women were aware that abortions were legal and available in public clinics, but they were concerned about negative and judgmental attitudes from health care providers even though some women were aware of the possible health safety issues related to seeking an abortion outside of the clinic setting. Abortion services should adapt to women's needs and offer them options of facility-based care but also self-managed medical abortions under the guidance of health care providers.

The no-go zone: a qualitative study of access to sexual and reproductive health services for sexual and gender minority adolescents in Southern Africa.

BACKGROUND: Adolescents have significant sexual and reproductive health needs. However, complex legal frameworks, and social attitudes about adolescent sexuality, including the values of healthcare providers, govern adolescent access to sexual and reproductive health services. These laws and social attitudes are often antipathetic to sexual and gender minorities. Existing literature assumes that adolescents identify as heterosexual, and exclusively engage in (heteronormative) sexual activity with partners of the opposite sex/gender, so little is known about if and how the needs of sexual and gender minority adolescents are met. METHODS: In this article, we have analysed data from fifty in-depth qualitative interviews with representatives of organisations working with adolescents, sexual and gender minorities, and/or sexual and reproductive health and rights in Malawi, Mozambique, Namibia, Zambia and Zimbabwe. RESULTS: Sexual and gender minority adolescents in these countries experience double-marginalisation in pursuit of sexual and reproductive health services: as adolescents, they experience barriers to accessing LGBT organisations, who fear being painted as "homosexuality recruiters," whilst they are simultaneously excluded from heteronormative adolescent sexual and reproductive health services. Such barriers to services are equally attributable to the real and perceived criminalisation of consensual sexual behaviours between partners of the same sex/gender, regardless of their age. DISCUSSION/ CONCLUSION: The combination of laws which criminalise consensual same sex/gender activity and the social stigma towards sexual and gender minorities work to negate legal sexual and reproductive health services that may be provided. This is further compounded by age-related stigma regarding sexual activity amongst adolescents, effectively leaving sexual and gender minority adolescents without access to necessary information about their sexuality and sexual and reproductive health, and sexual and reproductive health services.

Women's experiences seeking informal sector abortion services in Cape Town, South Africa: a descriptive study.

BACKGROUND: In settings where abortion is legally restricted, or permitted but not widely accessible, women face significant barriers to abortion access, sometimes leading them to seek services outside legal facilities. The advent of medication abortion has further increased the prevalence of informal sector abortion. This study investigates the reasons for attempting self-induction, methods used, complications, and sources of information about informal sector abortion, and tests a specific recruitment method which could lead to improved estimates of informal sector abortion prevalence among an at-risk population. METHODS: We recruited women who have sought informal sector abortion services in Cape Town, South Africa using respondent driven sampling (RDS). An initial seed recruiter was responsible for initiating recruitment using a structured coupon system. Participants completed face-to-face questionnaires, which included information about demographics, informal sector abortion seeking, and safe abortion access needs. RESULTS: We enrolled 42 women, nearly one-third of whom reported they were sex workers. Thirty-four women (81%) reported having had one informal sector abortion within the past 5 years, 14% reported having had two, and 5% reported having had three. These women consumed home remedies, herbal mixtures from traditional healers, or tablets from an unregistered provider. Twelve sought additional care for potential warning signs of complications. Privacy and fear of mistreatment at public sector facilities were among the main reported reasons for attempting informal sector abortion. Most women (67%) cited other community members as their source of information about informal sector abortion; posted signs and fliers in public spaces also served as an important source of information. CONCLUSIONS: Women are attempting informal sector abortion because they seek privacy and fear mistreatment and stigma in health facilities. Some were unaware how or where to seek formal sector services, or believed the cost was too high. Many informal methods are ineffective and unsafe, leading to potential warning signs of complications and continued pregnancy. Sex workers may be at particular risk of unsafe abortion. Based on these results, it is essential that future studies sample women outside of the formal health sector. The use of innovative sampling methods would greatly improve our knowledge about informal sector abortion in South Africa.

Is self-assessment of medical abortion using a low-sensitivity pregnancy test combined with a checklist and phone text messages feasible in South African primary healthcare settings? A randomized trial.

OBJECTIVE: To evaluate feasibility of self-assessment of medical abortion outcome using a low-sensitivity urine pregnancy test, checklist and text messages. The study assessed whether accurate self-assessment required a demonstration of the low-sensitivity urine pregnancy test or if verbal instructions suffice. METHODS: This non-inferiority trial enrolled 525 adult women from six public sector abortion clinics. Eligible women were undergoing medical abortion at gestations within 63 days. Consenting women completed a baseline interview, received standard care with mifepristone and home-administration of misoprostol. All were given a low-sensitivity urine pregnancy test and checklist for use 14 days later, sent text reminders, and asked to attend in-clinic follow-up after two weeks. Women were randomly assigned 1:1 to an instruction-only group (n = 262; issued with pre-scripted instructions on the low-sensitivity pregnancy test), or a demonstration group (n = 263; performed practice tests guided by lay health workers). The primary outcome was accurate self-assessment of incomplete abortion, defined as needing additional misoprostol or vacuum aspiration. Analysis was by intention to treat and a non-inferiority margin was set to six percentage points. Women's acceptability of their abortion procedure and preferences for follow-up were also assessed. RESULTS: Follow-up was 81% for abortion outcome, confirmed in-clinic at two weeks or self-reported within six months. Non-inferiority of instruction-only to a demonstration was inconclusive for accurate self-assessment (risk difference for instruction-only -demonstration: -2.5%; 95%CI: -9% to 4%). Comparing instruction-only to demonstration groups, 99% and 100% found the pregnancy test easy to do; and 91% and 93% respectively chose the pregnancy test, checklist and text messages for abortion outcome assessment in the future. CONCLUSION: Routine self-assessment using a low-sensitivity pregnancy test, checklist and text messages is feasible and preferred by women attending South African primary care abortion clinics. Counselling with additional emphasis on prompt recognition of ongoing pregnancies is recommended. TRIAL REGISTRATION: ClinicalTrials.gov NCT02231619.

Point-of-care CD4 testing to inform selection of antiretroviral medications in south african antenatal clinics: a cost-effectiveness analysis.

BACKGROUND: Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays. METHODS: We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO "Option A"): antenatal zidovudine (CD4 ≤350/µL) or ART (CD4>350/µL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/life-year saved). RESULTS: In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs. CONCLUSIONS: In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.

Comparison of point-of-care versus laboratory-based CD4 cell enumeration in HIV-positive pregnant women.

INTRODUCTION: Early initiation of antiretroviral therapy (ART) in eligible pregnant women is a key intervention for prevention of mother-to-child transmission (PMTCT) of HIV. However, in many settings in sub-Saharan Africa where ART-eligibility is determined by CD4 cell counts, limited access to laboratories presents a significant barrier to rapid ART initiation. Point-of-care (POC) CD4 cell count testing has been suggested as one approach to overcome this challenge, but there are few data on the agreement between POC CD4 cell enumeration and standard laboratory-based testing. METHODS: Working in a large antenatal clinic in Cape Town, South Africa, we compared POC CD4 cell enumeration (using the Alere Pima(TM) Analyzer) to laboratory-based flow cytometry in consecutive HIV-positive pregnant women. Bland-Altman methods were used to compare the two methods, including analyses by subgroups of participant gestational age. RESULTS: Among the 521 women participating, the median gestational age was 23 weeks, and the median CD4 cell count according to POC and laboratory-based methods was 388 and 402 cells/µL, respectively. On average, the Pima POC test underestimated CD4 cell count relative to flow cytometry: the mean difference (laboratory test minus Pima POC) was 22.7 cells/µL (95% CI, 16.1 to 29.2), and the limits of agreement were -129.2 to 174.6 cells/µL. When analysed by gestational age categories, there was a trend towards increasing differences between laboratory and POC testing with increasing gestational age; in women more than 36 weeks' gestation, the mean difference was 45.0 cells/µL (p=0.04). DISCUSSION: These data suggest reasonable overall agreement between Pima POC CD4 testing and laboratory-based flow cytometry among HIV-positive pregnant women. The finding for decreasing agreement with increasing gestational age requires further investigation, as does the operational role of POC CD4 testing to increase access to ART within PMTCT programmes.