Determinants of cervical cancer screening among women living with HIV in Zimbabwe.

In sub-Saharan Africa (SSA), cervical cancer (CC) is the second leading cause of cancer-related deaths, with human immunodeficiency virus (HIV) seropositive women being particularly vulnerable. Despite the benefits of early CC screening in reducing HIV-related CC deaths, CC screening uptake remains limited, with wide disparities in access across SSA. As part of a larger study, this paper examines the determinants of CC screening among HIV-seropositive women of reproductive age (15-49 years) in Zimbabwe. Using the 2015 Zimbabwe Demographic and Health Survey, we conducted multilevel analyses of CC screening among 1490 HIV-seropositive women, nested in 400 clusters. Our findings revealed that, even though 74% of HIV-seropositive women knew about CC, only 17.6% of them reported ever screening for it. Women who held misconceptions about HIV (OR = 0.47, p = 0.01) were less likely to screen for CC compared to those with accurate knowledge about HIV and CC. HIV-seropositive women with secondary or higher education were more likely to screen (OR = 1.39, p = 0.04) for CC compared to those with a primary or lower level of education. Age was positively associated with screening for CC. Furthermore, locational factors, including province and rural-urban residence, were associated with CC screening. Based on these findings, we call for integrated care and management of HIV and non-communicable diseases in Southern Africa, specifically, Zimbabwe due to the legacy of HIV in the region.

Knowledge of sexual partner's HIV serostatus and the practice of safer sex among heterosexual men of African descent in London, Ontario.

Objective: Poor knowledge of sexual partners' HIV status is a major contributing factor in the heterosexual spread of HIV in Canada. This study examined knowledge of sexual partner's HIV serostatus and the practice of safer sex among self-identified heterosexual African, Caribbean and Black (ACB) men in London, Ontario.Design: A cross-sectional data was collected from 156 heterosexual ACB men in London. The negative log-log link function was fitted to estimate the relationship between knowledge of sexual partner's HIV status and condom use among ACB men.Results: Findings show that ACB men who know their sexual partner's HIV status are less likely to use condoms compared to men who do not know the serostatus of their sexual partner, controlling for other theoretically relevant covariates. In addition, the findings show that sexually active, single ACB men are less likely to use condoms. On the other hand, ACB men with higher education, employed and with income over 60 thousand dollars a year have a higher likelihood of using condoms.Conclusions: Heterosexual ACB men who used condoms even when they did not know their sexual partners' HIV status could be explained as a resilience-building strategy in response to their increasing HIV vulnerabilities. Heterosexual ACB men's use of condoms is further associated with socioeconomic factors including income, employment and education that need to be addressed for an improved safer sex.

Concurrent sexual partnerships and HIV testing among heterosexual Black men in Ontario, Canada: findings from the weSpeak study.

BACKGROUND: African, Caribbean, and Black men constitute the second-highest category of males living with HIV in Ontario, which increased from 15.4% to 17% between 2011 and 2016. Previous studies have attributed this disproportionately higher rate to multiple concurrent sexual partnerships and low rates of HIV testing. Drawing on theoretical constructs of the health belief model (HBM), this study examined the relationship between multiple concurrent sexual partnerships and the uptake of HIV testing services among heterosexual Black men in Ontario. METHODS: Using a cross-sectional sample data of 829 individuals from four cities in Ontario, we employed the multinomial logit analysis to examine the relationship between multiple sexual partnerships and the uptake of HIV testing services among heterosexual Black men. RESULTS: The findings show that heterosexual Black men with multiple concurrent sexual partners were more than twice (RRR = 2.306, P < 0.01) as likely to test for HIV within the past 12 months when compared to those with one partner. Furthermore, being an immigrant, having good knowledge of HIV transmission, and earning lower annual income predicted higher odds of testing while sexual debut between the ages of 16 and 20 years, no visit to a healthcare provider in the past year and difficulty accessing healthcare significantly predicted lower likelihood of testing for HIV. CONCLUSIONS: These findings align with the theoretical constructs of the health belief model but more importantly, they suggest heterosexual Black men with concurrent sexual partners may be aware of their HIV risk and are taking measures to know their serostatus. Hence, making HIV screening services accessible and at safer spaces could increase their use of HIV screening services.

Sexual Debut Among Heterosexual Men of African and Caribbean Descent: Are the Youth Initiating Sex Earlier than the Older Generation?

Although age at first sex is considered a measure of sexual risk and vulnerability for HIV infection, there is a dearth of literature on age at sexual debut in the Canadian context. This study examined time variations to first sex among heterosexual African, Caribbean, and Black (ACB) men in four Ontarian cities. A population-based retrospective survey (n = 879) on timing to first sexual intercourse was conducted between 2018 and 2019 among self-identified heterosexual ACB men 16 years or older and residing in London, Ottawa, Toronto or Windsor. We used the lognormal survival analysis technique to examine variations in time to first sexual intercourse among age cohorts and between cities. The findings showed a generational shift in the pattern of sexual initiation, with younger heterosexual ACB men initiating sexual intercourse earlier compared with those currently older than 50 years. We observed those between 16 and 19 years, 20 and 29 years, and 30 and 39 years of age to have significantly higher risk ratios of TR = 0.852, TR = 0.869, and TR = 0.855, respectively. At city level, the results show marked spatial variations, with youth in cities of Toronto, Ottawa, and London at the highest risk of early sexual debut relative to those in Windsor. Early initiation of first sexual intercourse among heterosexual ACB youth was observed with those in the larger cities being at a relatively higher risk. There is the need for programs aimed at delaying sexual debut among youth in general. It is, however, important to recognize the relative risk of those in the larger cities.

Motherhood among Black women living with HIV: A "north-south" comparison of sociocultural and psychological factors.

We compared factors mediating motherhood experiences among Black nursing mothers living with HIV in two North American cities to one African city. Motherhood was measured with the Being a Mother Scale, and we compared their predictors between the two continents using difference in difference estimation within hierarchical linear modeling. Cultural beliefs congruent with infant feeding guidelines and social support had significant positive but differing effects on motherhood in the two continents. Perceived stress had significant negative impact on motherhood in the two continents. Due considerations to sociocultural contexts in policy development, HIV interventions and education of health care providers were recommended.

Determinants of risky sexual behaviours among adolescents in Central African Republic, Eswatini and Ghana: evidence from multi-indicator cluster surveys.

Despite the declining HIV/AIDS prevalence globally, nearly half of all new HIV infections still occur among youth, especially in sub-Saharan Africa. While determinants of risky sexual behaviour have received copious attention in the literature, we still lack multi-country studies that track regional changes in sexual risk among youth in sub-Saharan Africa. This study seeks to fill part of this gap by identifying the determinants of risky sexual behaviours among adolescents in Ghana, Central African Republic (CAR) and Eswatini (formerly Swaziland). We used nationally representative sample data from the Multi Indicator Cluster survey, round four (MICS4). Results of the descriptive analysis show that overall consistent condom use is still extremely low in sub-Saharan Africa. In Ghana, only 8.5% of male youth and 7% of female youth consistently use condoms. In CAR this figure is 8% and 4% in male youth and female youth respectively. In Eswatini, with one of highest HIV prevalence in the world, the prevalence of consistent condom use is at 29% in males and 20% in females, higher than both in Ghana and CAR. Results of hierarchical models show that age at first sex does not predict risky sexual behaviour in Ghana, but it does predict risky sexual behaviour in CAR although only among young males. In Swaziland, age at first sex predicts risky sexual behaviour in both male and female youth but the relationship is not in the expected direction. Low socio-economic status predicts inconsistent condom use in all the three countries, but only among young females. This paper provides relevant policy lessons and recommendations.

Informal transit, socio-spatial exclusion, and changing geographies of HIV/AIDS in urban Malawi.

The role played by the transport sector in the regional spread of HIV in sub-Saharan Africa is well known, yet attention has remained confined to entertainment hotspots and stopping places along long-distance highways and cross-border transport corridors. This paper draws attention to informal modes of transit prevalent in sub-Saharan African cities, by linking the rise of two-wheeled, manually operated bicycles, known as "Sacramento", to the potential spread of HIV and AIDS in Malawi. The findings of a qualitative study from Mzuzu city show that Sacramento operators are prone to demanding or accepting sexual favours from female commuters as payment for a ride. We draw on complementary theories of the political ecology of health (PEH) and feminist political ecology to show how a popular belief that Sacramento is an inferior mode of urban transit underpins risky sexual behaviour among men hired to operate this informal mode transport. The findings further show that operators' responses to this perceived inferiority are themselves also driven by gender discourses that seek to validate their identities as powerful go-getters. These scripts also create an environment that fosters multiple sexual partners and venerates unprotected sex. Because Sacramento is both a source of livelihood and an HIV risk milieu, it epitomises the contraction inherent in HIV and AIDS vulnerability in sub-Saharan Africa.

Circumcision Status and Time to Sexual Debut Among Youth in Sub-Saharan Africa: Evidence from Six Demographic and Health Surveys.

This paper examines the relationship between circumcision status and timing of sexual debut among unmarried youth in Sub-Saharan Africa using Demographic and Health Surveys. Results from survival analysis indicate that the association between circumcision and timing of first sex is place and context specific. Compared to uncircumcised, circumcised men in Rwanda, Uganda and Namibia hasten sexual initiation, whilst circumcised youth in Ethiopia and Mali delayed sex initiation. In Togo however, we found parity in timing to sexual debut. Our multivariate results reveal that, knowledge of HIV/AIDS risk and educational level also feed into the association between circumcision and timing of sex initiation- implying that efforts to prevent new HIV infection through circumcision could benefit from a proper understanding of how diverse set of factors interact in specific contexts to shape youth's decisions to initiate early sex.

Persistent misconceptions about HIV transmission among males and females in Malawi.

BACKGROUND: The prevalence of HIV in Malawi is one of the highest in sub-Saharan Africa, and misconceptions about its mode of transmission are considered a major contributor to the continued spread of the virus. METHODS: Using the 2010 Malawi Demographic and Health Survey, the current study explored factors associated with misconceptions about HIV transmission among males and females. RESULTS: We found that higher levels of ABC prevention knowledge were associated with lower likelihood of endorsing misconceptions among females and males (OR = 0.85, p < 0.001; OR = 0.85, p < 0.001, respectively). Compared to those in the Northern region, both females and males in the Central (OR = 0.54, p < 0.001; OR = 0.53, p < 0.001, respectively) and Southern regions (OR = 0.49, p < 0.001; OR = 0.43, p < 0.001, respectively) were less likely to endorse misconceptions about HIV transmission. Moreover, marital status and ethnicity were significant predictors of HIV transmission misconceptions among females but not among males. Also, household wealth quintiles, education, religion, and urban-rural residence were significantly associated with endorsing misconceptions about HIV transmission. CONCLUSION: Based on our findings, we recommend that education on HIV transmission in Malawi should integrate cultural and ethnic considerations of HIV/AIDS.

Investigating the disparities in cervical cancer screening among Namibian women.

OBJECTIVES: We examined the influence of knowledge and information, health care access and different socio-economic variables on women's decision to screen for cervical cancer using a nationally representative dataset. METHODS: We use hierarchical binary logit regression models to explore the determinants of screening for cervical cancer among women who reported hearing about cervical cancer. This enabled us to include the effect of unobserved heterogeneity at the cluster level that may affect screening behaviors. RESULTS: Among women who have heard about cervical cancer (N=6542), only 39% of them did undergo screening with a mean age of 33 years. The univariate results reveal that women who are educated, insured, can afford money needed for treatment and reported distance not a barrier to accessing healthcare were more likely to screen. Our multivariate results indicate that insured women (OR=1.89, p=0.001) and women who had access to information through education and contact with a health worker (OR=1.41, p=0.001) were more likely to undertake screening compared to uninsured women and those with no contact with a health personnel, after controlling for relevant variables. CONCLUSIONS: The adoption of a universal health insurance scheme that ensures equity in access to health care and extension of public health information targeting women in rural communities especially within the Caprivi region may be needed for a large scale increase in cervical cancer screening in Namibia.

Gestational Age at First Antenatal Care Visit in Malawi.

OBJECTIVES: This paper examines the gestational age at first antenatal care (ANC) visit and factors associated with timely initiation of ANC in Malawi in a context where maternal and child health services are generally provided for free. METHODS: Lognormal survival models are applied to Demographic and Health Survey data from a nationally representative sample of women (n = 13,588) of child-bearing age. RESULTS: The findings of this study show that less than 30 % of pregnant women initiate ANC within the World Health Organization recommended gestational timeframe of 16 weeks or earlier. The hazard analysis shows a gradient in the initiation of ANC by maternal education level, with least educated mothers most likely to delay their first ANC visit. However, after adjusting for variables capturing intimate partner violence in the multivariate models, the effect of maternal education attenuated and lost statistical significance. Other significant predictors of gestational age at first ANC include media exposure, perceived distance from health facility, age, and birth order. CONCLUSIONS FOR PRACTICE: The findings of the study link domestic violence directly with the gestational age at which mothers initiate ANC, suggesting that gender-based violence may operate through delayed initiation of ANC to undermine maternal and child health outcomes.

Orphan status and time to first sex among adolescents in northern Malawi.

This study examines the effects of orphanhood status on the timing of first sexual intercourse among youth in Malawi. Log-normal models were applied to survey data collected between May and August 2009 from 1,214 adolescents aged 12-18 in Mzuzu, Northern Malawi. Results of this study show that orphanhood is a significant predictor of age at first sex. Male double orphans experienced first sexual intercourse earlier than their male non-orphan peers. Similarly, female maternal and paternal orphans had their sexual debut faster than their non-orphan counterparts. The introduction of social support variables accounted for the orphanhood disadvantage. These findings suggest that in order to delay sexual initiation and reduce HIV risk among orphans in Malawi, policy efforts should focus on enhancing factual knowledge about HIV/AIDS, household food security, social support, and other measures that will strengthen existing social support networks and connectedness of surviving family members.

Circumcision status and time to first sex among never-married young men in Malawi: evidence from the demographic and health survey.

This study examines the association between circumcision status and the timing of first sexual intercourse among adolescents in Malawi. Results of survival models applied to nationally representative sample of never-married young men aged between 15 and 24 obtained from the Demographic and Health Survey data show that being circumcised is associated with earlier initiation of sexual activity in Malawi. Young men who reported being circumcised experienced their first sexual intercourse earlier in life than their uncircumcised counterparts. Although the introduction of theoretically relevant knowledge, socio-cultural, demographic, and socioeconomic variables in the multivariate models attenuated the association between circumcision and earlier sexual initiation, the relationship nonetheless remained robust. The study concludes by discussing the implications of these findings and suggests relevant policy recommendations.

Immigrant generational status and the uptake of HIV screening services among heterosexual men of African descent in Canada: Evidence from the weSpeak study.

Objective: Canada became a preferred destination for many non-European and non-American migrants since the introduction of favorable immigration policies in the late 1960 s. Blackimmigrants from the African and Caribbean regions however are a known vulnerable population to HIV infection in Canada. Even though first-generation immigrants might differ from subsequent generations in terms of culture and beliefs which are important for health outcomes and behaviors, research examining disparities in their use of preventative healthcare is limited. This study aimed to examine generational disparities in the uptake of HIV screening services among a sample of heterosexual Black men in Ontario, Canada. Methods: We used data from a cross-sectional survey sample (n = 829) that was collected from heterosexual Black men in four Ontarian cities (Toronto, Ottawa, London and Windsor) between March 2018 and February 2019. We used the negative log-log link function of the binomial family to examine the independent relationship between immigration status and the uptake of HIV testing and the cumulative effect of other predictor variables on HIV testing in nested models. Results: Findings from multivariate analysis show second-generation immigrants were significantly less likely to test for HIV compared with their first-generation immigrant counterparts. After controlling for theoretically relevant variables, the second-generation immigrants were 53% less likely to test for HIV. We further observed that participants with good knowledge of HIV transmission (OR=1.05; p > 0.05) and those who were older were more likely to test for HIV. Those with masculine tendencies (OR=0.98; p > 0.05) and those who reported not having sexual partner were less likely to test (OR=0.57; p > 0.01). Religion emerged as a significant predictor of HIV testing as Christians (OR=1.62; p > 0.05) and other believers (OR=1.59; p > 0.05) were more likely to test for HIV when compared to their Muslim counterparts. Conclusion: HIV prevention policies may need not only prioritize first-generation immigrants, but the wellbeing of their descendants as well. This could be achieved by implementing programs that will enhance second-generation immigrants' use of HIV screening services. Additionally, HIV educational programs would be of relevance and especially so as respondents with good knowledge of HIV transmission consistently demonstrated higher likelihood of testing for their HIV status.

HIV-Related Stigma Among Black Mothers in Two North American and One African Cities.

HIV-related stigma is a negative attitude or behaviour towards persons living with HIV, and is detrimental to effective care, management, and treatment of HIV. Using a revised 10-item stigma scale, we compared levels of HIV-related stigma and its correlates among Black women living with HIV in Ottawa, Canada, and Miami, FL, USA, with those in Port Harcourt, Nigeria. HIV-related stigma scores were calculated, with a maximum score of 10 and averaged 4.71 in Ottawa, 5.06 in Miami, and 3.78 in Port Harcourt. No significant difference in HIV-related stigma scores between Ottawa and Miami. HIV-related stigma was significantly (p < 0.05) higher among women in the North American cities compared with women in the African city. Hierarchical linear modelling shows that psychosocial variables contributed to variations in HIV-related stigma in Ottawa (22.3%), Miami (36.3%), and Port Harcourt (14.1%). At p < 0.05, discrimination was a significant predictor of increased HIV-related stigma in Ottawa (ß = 0.077), Miami (ß = 0.092), and Port Harcourt (ß = 0.068). Functional social support had a significant diminishing effect on HIV-related stigma in Miami (ß = - 0.108) and Port Harcourt (ß = - 0.035). Tackling HIV-related sigma requires sociocultural considerations within specific regional and national contexts.

A/C study protocol: a cross-sectional study of HIV epidemiology among African, Caribbean and Black people in Ontario.

INTRODUCTION: African, Caribbean and Black (ACB) communities are disproportionately infected by HIV in Ontario, Canada. They constitute only 5% of the population of Ontario yet account for 25% of new diagnoses of HIV. The aim of this study is to understand underlying factors that augment the HIV risk in ACB communities and to inform policy and practice in Ontario. METHODS AND ANALYSIS: We will conduct a cross-sectional study of first-generation and second-generation ACB adults aged 15-64 in Toronto (n=1000) and Ottawa (n=500) and collect data on sociodemographic information, sexual behaviours, substance use, blood donation, access and use of health services and HIV-related care. We will use dried blood spot testing to determine the incidence and prevalence of HIV infection among ACB people, and link participant data to administrative databases to investigate health service access and use. Factors associated with key outcomes (HIV infection, testing behaviours, knowledge about HIV transmission and acquisition, HIV vulnerability, access and use of health services) will be evaluated using generalised linear mixed models, adjusted for relevant covariates. ETHICS AND DISSEMINATION: This study has been reviewed and approved by the following Research Ethics Boards: Toronto Public Health, Ottawa Public Health, Laurentian University; the University of Ottawa and the University of Toronto. Our findings will be disseminated as community reports, fact sheets, digital stories, oral and poster presentations, peer-reviewed manuscripts and social media.

Breast cancer screening among women in Namibia: explaining the effect of health insurance coverage and access to information on screening behaviours.

OBJECTIVES: Breast cancer contributes substantially to morbidity and mortality in Namibia as is the case in most countries in Sub-Saharan Africa (SSA). However, there is a dearth of nationally representative studies that examine the odds of screening for breast cancer in Namibia and SSA at large. This paper aims to fill this gap by examining the determinants of breast cancer screening guided by the Health Belief Model. METHODS: We applied hierarchical binary logit regression models to explore the determinants of breast cancer screening using the 2013 Namibia Demography and Health Survey (NDHS). We accounted for the effect of unobserved heterogeneity that may affect breast cancer, testing behaviours among women cluster level. The NDHS is a nationally representative dataset that has recently started to collect information on cancer screening. RESULTS: The results show that women who have health insurance coverage (odds ratio (OR) = 1.62, p ≤ 0.01), maintain contact with health professionals (OR = 1.47, p = 0.01), and who have secondary (OR = 1.38, p = 0.01) and higher (OR = 1.77, p ≤ 0.01) education were more likely to be screened for breast cancer. Factors that influence women's perception of their susceptibility to breast cancer such as birthing experience, age, region and place of residence were associated with screening in this context. CONCLUSIONS: Overall, the health belief model predicted women's testing behaviours and also revealed the absence of relevant risk factors in the NDHS data that might influence screening. Overall, our results show that strategies for early diagnosis of breast cancer should be given major priority by cancer control boards as well as ministries of health in SSA. These strategies should centre on early screening and may involve reducing or eliminating barriers to health care, access to relevant health information and encouraging breast self-examination.

Pregnancy intention and gestational age at first antenatal care (ANC) visit in Rwanda.

BACKGROUND: With antenatal care (ANC) coverage now widely seen as a success story in Sub-Sahara Africa (SSA), attention has begun to shift towards exploring the full life-saving potential that ANC holds. OBJECTIVES: This study examines association between pregnancy intention and gestational age at first antenatal care (ANC) visit in Rwanda, where ANC coverage is nearly universal. METHODS: We use survival analysis and apply the lognormal model in Stata SE 15 to compute time ratios (TR) that provide a direct metric for time to first ANC check-up. RESULTS: Despite nearly universal coverage, only 25% of pregnant mothers start ANC within the timeframe recommended by WHO. Women with unintended pregnancies are even more likely to delay ANC (TR = 11.4%, Z = 2.48, p < 0.05) than women with intended pregnancies. The effect of pregnancy intention on time to first ANC accentuates when we control for parity in the hazard models. There is also educational divide, with early start of ANC limited to pregnant women with secondary education or higher. Interaction effects suggest significant interaction between parity (≥ 4) and unintended pregnancy (TR = 11.1%, Z = -2.07, p < 0.05) on gestational age at first ANC. Other predictors of time to first ANC are contact with health care provider and perceived barriers. CONCLUSION: With near universal coverage, the next big challenge to harness the full life-saving potential of ANC in Rwanda would be ramping up prompt start of prenatal care, timeliness of successive checkup intervals, and adherence to recommended number of visits, as opposed to simply increasing attendance. Preventing unwanted pregnancies in multiparous mothers through family planning would also significantly to the goal of universal ANC coverage in Rwanda.

Men's perceptions of women's reproductive health in South Sudan.

This paper draws on a qualitative study (n = 52) and applies a political ecology of health framework to examine men's perceptions of women's reproductive health in South Sudan. The findings suggest that political practices of place making configure men's views of women's reproductive roles in this new nation state. In particular, masculinity intertwines with fears of losing traditional culture, and with lingering concerns about sovereignty to underpin men's deep aversion to modern family planning methods. In addition, the use of tribal militia to control territory and leverage political power places women's reproduction at the centre of South Sudan's post-secession politics. Improving health in such a fragile environment may require more than rebuilding the health infrastructure and guaranteeing financial access to health care.